color atlas of melanocytic lesions of the skin - h. soyer, et al., (springer, 2007)

H. P Soyer, G Argenziano, R Hofmann-Wellenhof, R. H Johr (Eds.) Color Atlas of Melanocytic Lesions of the Skin H. P Soyer G Argenziano R Hofmann-Wellenhof R. H Johr (Eds.) Color Atlas of Melanocytic Lesions of the Skin With 366 Figures and 26 Tables 123 H Peter Soyer, MD, FACD Professor of Dermatology The Queensland Institute of Dermatology School of Medicine University of Queensland Princess Alexandra Hospital Brisbane, QLD 4102 Australia Giuseppe Argenziano, MD Professor of Dermatology  Department of Dermatology  Second University of Naples  Nuovo Policlinico – Edificio 13  Via Pansini I-80131 Naples Italy Rainer Hofmann-Wellenhof, MD Professor of Dermatology  Department of Dermatology Medical University Graz Auenbruggerplatz A-8036 Graz Austria Robert H Johr, MD Clinical Professor of Dermatology and Pediatrics Director, Pigmented Lesion Clinic University of Miami, School of Medicine Miami, FL 33136 USA Library of Congress Control Number: 2007924719 ISBN 978-3-540-35105-4  Springer Berlin Heidelberg New York This work is subject to copyright All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag Violations are liable for prosecution under the German Copyright Law Springer is a part of Springer Science+Business Media springer.com © Springer-Verlag Berlin Heidelberg 2007 The use of general descriptive names, registered names, trademarks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt   from the relevant protective laws and regulations and therefore free for general use Editor: Marion Philipp, Heidelberg, Germany Desk Editor: Ellen Blasig, Heidelberg, Germany Production: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany Cover design: Frido Steinen-Broo, EStudio, Calamar, Spain Reproduction and typesetting: am-productions GmbH, Wiesloch, Germany Printed on acid-free paper  24/3180/YL 5  4  3  2  1  This book is dedicated to the memory of Paolo Carli an outstanding scientist and a special human being H Peter Soyer and Giuseppe Argenziano on behalf of all authors Foreword Melanocytic tumors of the skin deserve special attention because of the following important facts Melanoma is frequent and early detection is critical ■ A correct interpretation is necessary because the implications may be very serious ■ It is a dynamically developing field where major progress has been made over the past decade ■ This atlas, written in a concise way, is a highly useful presentation that focuses on the full spectrum of pigmented skin tumors The prominent features include classical clinical as well as histopathological criteria for diagnosis, illustrations of excellent quality, as well as new concepts and practical aspects of management Of special interest are modern diagnostic techniques with emphasis on dermatoscopy Case studies and core messages indicating pathways of the diagnostic approach are at the end of each chapter All these features characterize the book as an impressive contribution to the literature in the area of melanocytic tumors My co-workers in Graz, Dr H Peter Soyer and Dr Rainer Hofmann-Wellenhof, as well as Dr Giuseppe Argenziano from Naples and Dr Robert Johr from Miami, together with many international contributors who are all experts in their respective disciplines, have produced a splendid piece of work which presents highly relevant information on a complex and challenging subject This book will greatly assist physicians in providing optimal care for patients with melanocytic skin lesions Helmut Kerl Professor & Chairman Department of Dermatology Medical University of Graz Austria Preface At the beginning of many scientific endeavors there is an idea shared by a small group of enthusiastic people This was the case with our group, friends and colleagues from Austria, Italy, and the United States Our idea was to write a color atlas of melanocytic skin lesions, with particular emphasis on the morphological dimension, using a systematic and logical approach As practicing dermatologists with backgrounds in dermoscopy and dermatopathology, we wanted to describe the many faces of benign and malignant pigmented skin lesions based on clinico-pathological and dermoscopic−pathological correlations Together with a large group of distinguished dermatologists from around the world, we prepared this atlas In 1894 Paul Gerson Unna published the textbook Histopathology of Skin Diseases His wellknown saying on the relationship between dermatology and histopathology has been slightly modified by us and now reads as follows: “The dermatologist is fortunate in being able to study the clinical and dermoscopic picture with his/ her histologically trained eye and the microscopic picture with his/her clinically and dermoscopically trained eye.” In this spirit we hope that you enjoy reading this atlas and that it will help you in your daily practice H Peter Soyer Giuseppe Argenziano Rainer Hofmann-Wellenhof Robert Johr Contents I.1 I.2 The Morphologic Dimension in the Diagnosis of Melanocytic Skin Lesions H  Peter Soyer and Elisabeth M.T Wurm III.3 Agminated Nevus 75 Ulrike Weigert and Wilhelm Stolz Clinical Examination of Melanocytic Neoplasms Including ABCDE Criteria Alfred W Kopf III.5 Atypical (Dysplastic) Nevus 87 R  ainer Hofmann-Wellenhof and H Peter Soyer III.4 Blue Nevus 78 G  erardo Ferrara and Giuseppe Argenziano III.6 Combined Nevus 97 Horacio Cabo III.7 Melanoma: the Morphological Dimension 23 Lorenzo Cerroni Common Nevus 102 R  ainer Hofmann-Wellenhof and H Peter Soyer III.8 II.1 Laser-Scanning Confocal Microscopy 39 Salvador González and Allan Halpern Congenital Melanocytic Nevi 106 A  lon Scope, Cristiane BenvenutoAndrade, Ashfaq A Marghoob III.9 II.2 Automatic Diagnosis 47 Josef Smolle Melanocytic Nevi on the Genitalia and Melanocytic Nevi on Other Special Locations 119 Ingrid H Wolf I.3 Dermoscopic Examination R  alph P Braun, Harold S Rabinovitz, Margaret Oliviero, Alfred W Kopf, Jean-Hillaire Saurat, Luc Thomas I.4 II.3 Multispectral Image Analysis 52 D  ina Gutkowicz-Krusin and Harold Rabinovitz II.4 Teledermatology 57 C  esare Massone, Elisabeth M.T Wurm, Rainer Hofmann-Wellenhof, Gian Piero Lozzi, H. Peter Soyer III.1 The Life of Melanocytic Nevi 61 Harald Kittler III.2 Acral Nevus 66 M  asaru Tanaka, Masayuki Kimoto, Toshiaki Saida III.10 Halo Nevus 124 A  lessandro Di Stefani and Sergio Chimenti III.11 Irritated Nevus and Meyerson’s Nevus 129 R  egina Fink-Puches, Iris Zalaudek, Rainer Hofmann-Wellenhof III.12 Melanocytic Lesions in Darker Racial Ethnic Groups 135 Heather Woolery-Lloyd III.13 Miescher Nevus 139 S  teven Q Wang, Harold H Rabinovitz, Alfred W Kopf XII Contents III.14 Nevi with Particular Pigmentation: Black, Pink, and White Nevus 142 I  ris Zalaudek, Robert Johr, Bernd Leinweber III.15 Recurrent Nevus 147 Andreas Blum III.16 Spitz Nevus and Its Variants 151 G  erardo Ferrara, Elvira Moscarella, Caterina M Giorgio, Giuseppe Argenziano III.17 Syndromes Involving Melanocytic Lesions 164 C  heryl G Aber, Elizabeth Alvarez Connelly, Lawrence A Schachner III.18 Nail Apparatus Nevus (Subungual Nevus, Nail Matrix Nevus) 173 Luc Thomas III.19 Unna Nevus 181 Susana Puig and Josep Malvehy IV.1 Epidemiology of Melanoma 185 Scott Kitchener IV.2 Acral Melanoma 196 T  oshiaki Saida, Hiroshi Koga, Yoriko Yamazaki, Masaru Tanaka IV.3 Amelanotic Melanoma 204 Jürgen Kreusch IV.7 Melanoma of the Face 233 Ulrike Weigert and Wilhelm Stolz IV.8 Melanoma of the Trunk and Limbs Including Superficial and Nodular Melanoma 237 Josep Malvehy and Susana Puig IV.9 Cutaneous Metastatic Melanoma 260 Maria Antonietta Pizzichetta IV.10 Scalp Melanoma 265 I  ris Zalaudek, Jason Giacomel, Bernd Leinweber IV.11 Nail Apparatus Melanoma (Subungual Melanoma, Nail Matrix Melanoma) 270 Luc Thomas V.1 Pigmented Basal Cell Carcinoma 279 Scott W Menzies V.2 Dermatofibroma 286 Domenico Piccolo and Ketty Peris V.3 Lentigines Including Lentigo Simplex, Reticulated Lentigo and Actinic Lentigo 290 Paolo Carli and Camilla Salvini V.4 Squamous Cell Carcinoma Including Actinic Keratosis, Bowens Disease, Keratoacanthoma, and Its Pigmented Variants 295 I  ris Zalaudek, Jason Giacomel, Bernd Leinweber Early Evolution of Melanoma (Small-Diameter Melanoma) 213 R  obert J Friedman, Melanie Warycha, Michele Farber, Dina GutkowiczKrusin, Harold Rabinovitz, David Polsky, Margaret Oliviero, Darrell S Rigel, Lori Kels, Edward R Heilman, Alfred W Kopf IV.5 False-Negative Melanomas 221 Robert Johr and Giuseppe Argenziano Subject Index 329 IV.6 Genital Melanoma 229 Ingrid H Wolf IV.4 V.5 Vascular Lesions 303 Fezal Özdemir V.6 Seborrheic Keratosis Including Lichen Planus-like Keratosis 313 Robert Johr List of Contributors C Aber Division of Pediatric Dermatology Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine Cedars Medical Center 1295 NW 14th Street, Suite K Miami, Florida 33125 E-mail: caber@med.miami.edu E Alvarez Connelly Division of Pediatric Dermatology Department of Dermatology and Cutaneous Surgery University of Miami, Miller School of Medicine Cedars Medical Center 1295 NW 14th Street, Suite K Miami, Florida 33125 USA E-mail: econnelly@med.miami.edu A Blum Associate Professor of Dermatology Seestraße 3a 78464 Konstanz Germany E-mail: a.blum@derma.de R.P Braun Department of Dermatology University Hospital Zurich 8091 Zurich Switzerland E-mail: braun@melanoma.ch H Cabo Section of Dermatology Instituto de Investigaciones Médicas “A Lanari” University of Buenos Aires Argentina E-mail: hcabo@fibertel.com.ar G Argenziano Department of Dermatology Second University of Naples Nuovo Policlinico − Edificio 13 Via Pansini 80131 Naples E-mail: argenziano@tin.it P Carli † Dipartimento di Scienze Dermatologiche Universita’ di Firenze Via degli Alfani, 37 50121 Florence Italy † Deceased C Benvenuto-Andrade Research Dermatologist Photomedicine and Telemedicine Laboratory Federal University of Rio Grande Sul Porte Alegre Brazil E-mail: cris@fornix.com.br L Cerroni Department of Dermatology Medical University of Graz Auenbruggerplatz 8036 Graz Austria E-mail: lorenzo.cerroni@meduni-graz.at Seborrheic Keratosis Chapter V.6 Fig. V.6.10.  Fingerprinting on the right and a variation of the fissure and ridge pattern on the left characterize this seborrheic keratosis Fig. V.6.11.  This seborrheic keratosis demonstrates typical hairpin-shaped blood vessels Another network-like pattern with foci of thicker-branched and dark-brown or black-line segments often with an abrupt cut-off at the periphery can be seen Histopathologically, it represents melanin in keratinocytes or melanocytes along the dermo-epidermal junction At times, the differentiation of all of these forms of network will not be possible One must formulate a dermoscopic differential diagnosis and search for more criteria to make a diagnosis Hairpin-shaped fine telangiectatic blood vessels are commonly seen in seborrheic keratosis (Fig. V.6.11) At times they can have a white halo surrounding them, indicating the keratinizing nature of the tumor They are also seen in melanocytic nevi, keratoacanthomas, basal cell carcinomas, and when thick and irregular, in melanomas The less pressure applied to the skin with instrumentation, the easier it will be to see these fine vessels Skill and minimal pressure is needed to capture good images of hairpin vessels with digital photography Flat seborrheic keratosis can also have irregular borders with small or large concave indentations that have been compared to moth-eaten garments “Moth-eaten” borders are a widely accepted criterion that can also be seen in solar lentigines Finally, if one looks carefully, the pigment on the surface of the skin in flat seborrheic keratosis can appear to be like “jelly spread over the skin.” The jelly sign would be one of the most difficult criterion to identify and least important in diagnosing seborrheic keratosis using dermoscopy V.6.4  elevant Clinical Differential R Diagnosis In most cases the clinical diagnosis of seborrheic keratosis, stuccokeratosis, and dermatosis papulosa nigra poses no problems; however, clinically atypical lesions can be challenging If in doubt, never hesitate to cut one out, because melanomas are not uncommonly misdiagnosed as seborrheic keratosis Clinical and dermoscopic features of both can be found in a single lesion In a retrospective study of 9204 cases submitted for histopathological examination with the clinical diagnosis of seborrheic keratosis, or a differential diagnosis including seborrheic keratosis, a significant number of cases turned out to be melanomas Verrucous melanomas might be especially difficult to differentiate clinically from seborrheic keratosis (Figs. V.6.12–V.6.14) [14] Clinically, they can also be confused with actinic keratosis, melanocytic nevi (Fig. V.6.15), verruca vulgaris, condyloma acuminatum, solar lentigines, in-situ and invasive squamous cell carcinoma, acrochordon, eccrine poromas, and epidermal nevi The patient’s personal and fam- 319 320 R Johr Fig. V.6.12.  At times it is very difficult to differentiate melanoma from a seborrheic keratosis In this case it was a seborrheic keratosis If one does not have a good clinicopathological correlation, another biopsy or another pathologist’s opinion can be considered Fig. V.6.13.  This large, well-demarcated scaly and greasy-appearing lesion was present for years without a history of any changes With dermoscopy multiple milialike cysts were thought to be seen reinforcing the diagnosis of a seborrheic keratosis V.6 ily history, plus the history of the lesion, should be taken into consideration For example, a seborrheic keratosis-like lesion in a 7-year-old most probably is an epidermal nevus Actinic keratosis tend to be more erythematous with poorly defined borders Melanocytic nevi are soft, compressible, non-scaly with a positive wobble sign If one observes a seborrheic keratosis-like lesion in the genital area, most probably it is a condyloma acuminatum Seborrheic keratosis is generally regarded as a benign tumor; however, melanocytic, nonmelanocytic, benign, and malignant pathologies have been associated with them (Fig. V.6.16) Seborrheic Keratosis Fig. V.6.14.  Another general dermoscopy principle is to eliminate scale to get a better picture After the scale was removed with a swipe of an alcohol prep, a different picture emerged This nodular melanoma demonstrated asymmetry of color and structure, irregular pigment network, globules and blotches, plus a diffuse blue-white structure Chapter V.6 321 Fig. V.6.16.  A collision lesion consisting of a melanocytic nevus and a seborrheic keratosis Fig. V.6.15.  The clinical and dermoscopic differential diagnosis includes a melanocytic nevus vs seborrheic keratosis In this case it was a seborrheic keratosis The association might be by chance, or seborrheic keratosis could be a precursor lesion since it contains all of the cells found in the normal skin Basal cell carcinoma, in-situ and invasive squamous cell carcinoma, keratoacanthomas, lentigo maligna, superficial spreading melano- ma, melanocytic and dysplastic nevi, actinic keratosis, actinic lentigo, and eccrine porocarcinoma have been reported to be associated with seborrheic keratosis Some researchers believe that the reticulated sub-type of seborrheic keratosis arises from solar lentigines The frequency of these associations varies from study to study [15–17] 322 R Johr Fig. V.6.17.  On the left is a collision tumor consisting of a basal cell carcinoma and a seborrheic keratosis On the right is another collision tumor, a squamous cell carci- V.6.5  istopathology H V.6 Seborrheic keratosis are true neoplasms and not a hyperplasia of the epidermis that have a variable proliferation of basaloid and squamous cells with pseudohorn cyst formation (Fig. V.6.17) Acanthotic, hyperkeratotic, reticulated, irritated, and clonal are the most common histological subtypes, and many show a mixture of patterns There are varying amounts of hyperkeratosis, acanthosis, papillomatosis, pigmentation, and inflammation Cytological atypia and perivascular, diffuse, or lichenoid chronic inflammatory infiltrates can be seen with irritated lesions The acanthotic subtype is most common with little hyperkeratosis or pap- noma with a seborrheic keratosis Did the malignancies arise from the seborrheic keratosis, a benign proliferation of basaloid and squamous cells? illomatosis and a greatly thickened epidermis The hyperkeratotic variant is the histological reverse of the acanthotic type with prominent hyperkeratosis, and papillomatosis while the reticulated or adenoid type demonstrates delicate strands of epithelium branching from the epidermis Intraepithelial nesting gives rise to the Borst–Jadassohn appearance of the clonal seborrheic keratosis and intradermal or inverted proliferation characterizes the inverted follicular keratosis Stuccokeratosis has histopathological features of hyperkeratotic seborrheic keratosis, usually without pseudohorn cyst formation, whereas dermatosis papulosa nigra has features of the acanthotic variant with pseudohorn cysts [18] Seborrheic Keratosis V.6.6  anagement M Seborrheic keratosis comes to clinical attention for cosmetic reason if they become symptomatic or appear to break into pieces for no apparent reason They account for a large number of o ­ ffice visits and significant health care costs Seborrheic keratosis that have undergone recent change, are symptomatic, or look suspicious clinically should be considered for der­ moscopic and histopathological evaluation Significant pathology, such as melanoma or basal cell carcinoma, could be surrounded by numerous seborrheic keratosis, or individual seborrheic keratosis could have malignant changes themselves Careful physical examination is essential Complete excision, rather than a shave or curettage, will be more helpful to the pathologist to evaluate for malignancy Treatment is most often for cosmetic reasons, so the least destructive method should be used Cryotherapy, with and without curettage, is the treatment of choice Shave excision, electrodesiccation, and CO2 laser vaporization are other methods of treatment that have increased risks of scarring V.6.7  ichen Planus-like Keratosis L V.6.7.1  efinition D Lichen planus-like keratosis (synonyms: benign lichenoid keratosis; solitary lichen planus; involuting lichenoid plaque) is a common benign tumor of adulthood V.6.7.2  linical Features C The pathogenesis of lichen planus-like keratosis is thought to be an immunologically mediated regression of an existing lesion This theory does not account for the lesions that develop de novo Ninety percent of these lesions are solitary macules or papules, occasionally nodules or plaques that develop between the third to seventh decade in Caucasians and which are occasionally seen in Hispanics, Asians, or African-Americans With a 2:1 female to male inci- Chapter V.6 dence, they are typically found on the upper trunk, distal upper extremities, and uncommonly, on the head and neck A small percentage of people can have two or three of these lesions There is a correlation of the clinical appearance with their chronicity and histopathological findings Acute, rapidly developing lichen planus-like lesions of less than 3 months tend to be erythematous or pinkish Subacute lesions of 3 months to 1 year have a dusky-red or violaceous color, and if present for more than 1 year, they are regularly or irregularly pigmented with shades of brown or gray The diagnosis can be suspected even before dermoscopy is used by seeing a small lesion with a combination of brown and gray colors The surface can be scaly, verrucous, or smooth and pearly They range in size from a few millimeters to a centimeter or more, and can be asymptomatic, slightly pruritic, or have a mildly stinging sensation Malignant degeneration of lichen planus-like keratosis has never been reported V.6.7.3  ermoscopy D Erythematous or pinkish lichen planus-like keratosis are featureless or feature poor with remnants of pigment network, subtle blotches of brown color, plus dotted, irregular linear, and other-shaped telangiectatic blood vessels (Fig. V.6.18) They cannot be distinguished clinically or dermoscopically from melanocytic, non-melanocytic benign, malignant, or inflammatory lesions that have the same characteristics including amelanotic melanoma With the pigmented variant, the dermoscopic picture depends on the age of the lesion Early lesions can have the dermoscopic features of a solar lentigo or flat seborrheic keratosis with “moth-eaten” borders, fingerprinting, milialike cysts, comedo-like openings plus small foci of melanophages Also referred to as peppering or granular dust, melanophages have a distinctive dermoscopic appearance with fine irregular dots that can be black, shades of brown, gray, or blue Typically they are smaller than the dots and globules seen in melanocytic lesions (Fig. V.6.19) 323 324 R Johr Fig. V.6.18.  Pinkish macules and papules can be melanocytic, non-melanocytic, benign, malignant, or inflammatory This worrisome papule was discovered hidden on the chest of a very hairy patient It is feature poor with dotted and linear irregular-shaped blood vessels It turned out to be a lichen planus-like keratosis and not amelanotic melanoma Fig. V.6.19.  Fingerprinting of a flat seborrheic keratosis can be seen on the right side of this lesion The grayishcolored fine dots representing melanophages on the left side are the most important clues in diagnosing this lichen planus-like keratosis V.6 As time passes increasingly more melanophages are seen, and they might be the only dermoscopic criteria found in older lesions (Fig. V.6.20) One can also see larger clumps of pigment plus foci of whitish color In the later stages of development, the dermoscopic differ- ential diagnosis could include regressive melanoma The clinical, dermoscopic, and histopathological differentiation might not be possible Special staining, such as S-100 and a good clinicopathological correlation, is advised Seborrheic Keratosis Chapter V.6 325 Fig. V.6.20.  Surgery can be avoided with this small oval lichen planus-like keratosis filled with melanophages There is no suggestion with dermoscopy that this could be a regressive melanoma; therefore, dermoscopy over rides the atypical clinical picture With experience one will not excise many lesions with this dermoscopic ­appearance V.6.7.4  elevant Clinical Differential R Diagnosis In most, but not all, cases the diagnosis of lichen planus-like keratosis is made after a skin biopsy The clinical impression does not usually correlate with the histopathology Past experience and a high index of suspicion are helpful The differential diagnosis includes basal cell carcinoma, especially when the surface is smooth and pearly, in-situ and invasive squamous cell carcinoma, actinic or seborrheic keratosis, pigmented dermatofibromas, and solar lentigines Older pigmented variants, especially if there is a history of change, should be differentiated from banal and dyspastic nevi or melanoma An erythematous or pinkish macule or papule cannot be differentiated clinically from amelanotic banal and dyspastic nevi, amelanotic melanoma, and even solitary inflammatory lesions such as psoriasis or granuloma annulare V.6.7.5  istopathology H In general, lichen planus-like keratosis are characterized by epidermal and dermal changes that reflect the age of the lesion The epidermis can be normal, acanthotic, or atrophic with hyperkeratosis, focal parakeratosis, and hypergranulosis Civatte colloid body formation representing necrotic keratinocytes is frequently found There are variable amounts of vacuolar degeneration of the basal cell layer plus a band-like lymphocytic infiltrate that can obscure the dermo-epidermal junction Melanin incontinence with melanophages, dermal scarring, plus variable numbers of eosinophils, plasma cells, histiocytes, and neutrophils can also be found Features of solar lentigo or seborrheic keratosis are often seen at the periphery of the lesion In a study of 1040 lichen planus-like keratosis, five histopathological subtypes were identified [19]: the classic and early interface types, plus bullous lesions with intra- and subepidermal vesiculation There was an atypical variant with at least five atypical lymphocytes and an absence of criteria to diagnose mycosis fungiodes In another retrospective study, 15 cases of mycosis-fungoides-pattern, lichen planuslike keratoses were presented that had Pautrier micro-abscesses, epidermotropism, and lymphocytes with hyperconvoluted nuclei [20] Atrophic late lesions were the last subtype identified 326 R Johr The classic, atypical, and bullous patterns were associated with erythematous or pinkish lesions Interface subtypes were erythematous to brown macules, whereas the late atrophic lesions tended to be grayish, violaceous, or irregularly pigmented The histopathological differential diagnosis is extensive and includes other conditions with a band-like infiltrate such as lichen planus, lichenoid lupus erythematosus, and lichenoid drug reactions Inflamed actinic and seborrheic keratosis, porokeratosis, melanocytic lesions, including melanoma, are also in the differential diagnosis Melanomas simulating lichen planus-like keratosis have increased numbers of atypical melanocytes that can be partially obscured by a dense lymphocytic infiltrate Pathologists considering the diagnosis of mycosis fungoides should search for criteria that might indicate that the lesion is a lichen planus-like keratosis Clinicopathological correlation plus dermoscopic examination will help the clinician make the differentiation V.6 V.6.7.6  anagement M In most cases lichen planus-like keratosis is found by physicians that perform careful skin examinations Baseline gross and digital dermoscopic images can be taken of minimally suspicious lesions to follow over time Side-byside comparisons of the baseline and follow-up images can be checked for significant changes When a more suspicious lesion is found, a complete excision, rather than an incisional biopsy, is recommended Since melanoma is in the differential diagnosis of pigmented and pinkish lesions, the pathologist will need the entire specimen for a complete evaluation Although the technique is controversial, skilled clinicians can accomplish this easily with a deep-shave excision Skin biopsies are not always needed, especially if the lesion is examined with dermoscopy and no high-risk criteria are identified Once the diagnosis is confirmed histopathologically, if part of the lesion remains, liquid nitrogen or electrosurgery and curettage can be performed Topical steroids can also be used, or they can be left alone Seborrheic Keratosis C Chapter V.6 Core Messages ■ Seborrheic keratosis are ubiquitous benign epidermal neoplasms that, in most but not all cases, can be diagnosed clinically and with dermoscopy; some will need a histopathological diagnosis ■ It is important to be aware of the clinical differential diagnosis of atypical lesions ■ Melanomas can be misdiagnosed as seborrheic keratosis, especially the verrucous variant Any lesion that looks suspicious clinically or with dermoscopy to be symptomatic or changing should be considered for histopathological evaluation ■ Seborrheic keratoses can be associated with melanocytic, non-melanocytic benign, or malignant pathology ■ Cutaneous malignancies can be surrounded and camouflaged by multiple seborrheic keratoses, or an individual seborrheic keratosis could undergo malignant change Careful physical examination is essential ■ The sudden appearance, irritation of pre-existing lesions, or regression of seborrheic keratosis is called the sign of Leser–Trelat and can be a cutaneous manifestation of an internal malignancy References   Hefferman MP, Khavari PA Raindrop seborrheic keratosis: a distinctive pattern on the backs of elderly patients Arch Dermatol 1998; 134:382–383   Hsu C, Abraham S Campanelli A et al Sign of Leser–Trelat in a heart transplant recipient Br J Dermatol 2005; 153(4):861–862   Patton T, Zirwas M, Nieland-Fisher N, Jukie D Inflammation of seborrheic keratoses caused by cytarabine: a pseudo sign of Leser–Trelat J Drugs Dermatol 2004; 3(5):565–566   Pentenero M, Carrozzo M, Pagano M, Gandolfo S Oral acanthosis nigricans, tripe palms and sign of Leser–Trelat in a patient with gastric adenocarcinoma Int J Dermatol 2004; 43(7):530–532 If the diagnosis is made, a comprehensive systemic work-up is indicated ■ Treatment is most often for cosmetic reasons and the least destructive and scarring method should be used ■ Lichen planus-like keratosis are usually diagnosed histopathologically Excisional, rather than incisional, techniques are recommended ■ The more skilled clinician can make the diagnosis by putting the clinical and dermoscopic findings together, thus avoiding surgery ■ There is an extensive clinical and histopathological differential diagnosis which includes melanoma, nonmelanoma skin cancer, and mycosis fungoides A good clinicopathological correlation is essential ■ Solitary erythematous or pinkish macules and papules could be melanocytic, non-melanocytic, benign, malignant, or inflammatory Dermoscopy is usually not helpful with these lesions ■ Once the diagnosis of a lichen planuslike lesion is made, aggressive therapy is not indicated Reassurance to the patient of the benign nature of this pathology will be appreciated   Inamadar AC, Palit A Eruptive seborrheic keratosis in human immunodeficiency virus infection: a coincidence or “the sign of Leser–Trelat?” Br J Dermatol 2003; 149(2):435–436   Flugman SL, McClain SA, Clark RA Transient eruptive seborrheic keratosis associated with erythrodermic psoriasis and erythrodermic drug eruption: report of two cases J Am Acad Dermatol 2001;45(6 Suppl):S212–S214   Vielhauer V, Herzinger T, Korting HC The sign of Leser–Trelat: a paraneoplastic cutaneous syndrome that facilitates early diagnosis of occult cancer Eur J Med Res 2000; 5(12):512–516   McCrary ML, Davis LS Sign of Leser–Trelat and mycosis fungoides J Am Acad Dermatol 1998; 38(4):644 327 328 R Johr   Braun RP, Rabinovitz HS, Krischer J et al Dermoscopy of pigmented seborrheic keratosis: a morphological study Arch Dermatol 2002; 138:1556–1560 10 Elgart GW Seborrheic keratosis, solar lentigines and lichenoid keratosis Dermatoscopic features and correlation to histology and clinical signs Dermatol Clin 2001; 19(2):347–357 11 Zalaudek I, Ferrara G, Argenziano G Clonal seborrheic keratosis: a dermoscopic pitfall Arch Dermatol 2004; 140:1169–1170 12 Hirata SH, Almeida FA, Tomimori-Yamashita J et al “Globulelike” dermoscopic structures in seborrheic keratosis Arch Dermatol 2004; 140:128–129 13 Argenziano G, Rossiello L, Scalvenzi M et al Melanoma simulating seborrheic keratosis: a Dermoscopy pitfall Arch Dermatol 2003; 139:389–391 14 Izikson L, Sober AJ, Mihm MC et al Prevalence of melanoma clinically resembling seborrheic keratosis Arch Dermatol 2002; 138:1562–1566 15 Vun Y, De’ambrosis B, Spelman L, et al Seborrheic keratosis and malignancy: collision tumour or malignant transformation? Australas J Dermatol 2006; 47(2):106–108 V.6 16 Lim C Seborrheic keratosis with associated lesions: a restrospective analysis of 85 lesions Australas J Dermatol 2006; 47(2):109–113 17 Johr R, Saghari S, Nouri K Eccrine porocarcinoma arising in seborrheic keratosis evaluated with dermoscopy and treated with Moh’s technique Int J Dermatol 2003; 42:653–657 18 Mckee PH et al (eds) Tumors of the surface epithelium Pathology of the skin, 3rd edition with clinical correlations, 2005; Elsever Mosby, Amsterdam, pp 1158–1163 19 Morgan MB, Stevens GL, Switlyk S Benign lichnoid keratosis A clinical and pathologic reappraisal of 1040 cases Am J Dermatopathol 2005; 27(5):387– 392 20 Higail IA, Crawford RI Benign lichenoid keratosis with histologic features of mycosis fungoides: clinicopathologic description of a clinically significant histologic pattern J Cutan Pathol 2002; 29:291–294 Subject Index A ABCD criteria/rule  88, 91, 214 ABCDE criteria  „Abtropfung“  61, 63 acanthosis  199 achromia  271 achromic melanoma  273 –  ungual  273 acquired monodactylic anonychia  271 acral –  lentiginous melanoma  238 –  melanoma  – – Clark’s classification  196 –  nevus  66 actinic –  keratosis  234, 267, 295, 296 –  lentigo, see also lentigo senilis  103, 225, 293 adenocarcinoma  315 adnexal neoplasm  82 agminated nevus  75, 80 albinismus perinaevicus, see also halo nevus  124 amelanotic melanoma  204, 221, 323 –  vascular pattern  208 AMS, see atypical mole syndrome anaplasia  299 angiokeratoma  248, 261, 303 –  solitary  307 angioma  261 –  acquired plaque-type  310 anhidrosis  108 apocrine hydrocysroma  82 astrocytoma  168 arborizing vessel  82 artificial light source  189 atypical –  dysplastic nevus  87 –  melanoma  211 –  mole syndrome (AMS)  88, 184, 187, 253 –  nevus – – central hyperpigmen- tation  91 – – central hypopigmen- tation  90 – – dermoscopic pattern  90 – – eccentric hyperpigmen tation  91 – – multifocal hyperpigmen tation  91 – – multifocal hypopigmen tation  91 –  spitzoid tumor  34 automated classification  47 automatic diagnosis  47 B baby Spitz nevus  159 basal cell carcinoma (BCC)  14, 15, 97, 144, 224, 279, 319 –  black patients  137 –  pigmented  234, 246 Becker’s nevus  111 Bednar tumor  247 benign –  fibrous histiocytoma  288 –  melanocytic proliferation  98 BK mole syndrome  88 black –  heel  69 –  lamella  13, 142, 143, 158 –  nevus  93, 142 blood –  spot  175 –  vessel  – – comma-shaped  139, 181 blotch  13, 48 blue nevus  179, 225, 247, 261, 265, 284 –  atypical variants  78 –  dendritic-sclerotic histotype  81 –  hypochromic variants  80 –  hypomelanotic  82 –  mixed types  78 –  with satellites  266 blue-white veil  13, 245 Bowenoid carcinoma  296 Bowen’s disease  273, 296, 297 –  non-pigmented  298 –  pigmented  298 B-RAF mutation  152 branched streak  244 C café-au-lait macule  111, 167, 168 capping  159 Carney syndrome  80, 169 CASH  17 CD4 gene  250 CDKN2A  168, 187, 250 cherry –  angioma  17 –  hemangioma  304 chromatin pattern  84 Civatte colloid body formation  325 Clark –  level  25 –  nevus  62, 63, 87, 97, 98, 147, 158, 286 –  melanoma  64 clinico-imaging technique  CNS melanocytosis  165 cobblestone  17 cockarde nevus  130 collagen  54 collision tumor  97 combined nevus  97 common nevus, see also typical nevus 102 condyloma acuminata  320 confocal –  laser scanning  47 –  microscopy  39 congenital melanocytic nevus  75, 106 –  treatment  112, 113 330 Subject Index crista profunda –  intermedia  200 –  limitans  68, 70 crush artifact  24 cryosurgery  167 cutaneous –  hemorrhagic macule  309 –  metastatic melanoma – – in-transit type  260 – – satellite type  260 cyclin D1  196, 200 D Dandy-Walker complex  165 dermal –  elastosis  188 –  melanoma  27, 30 dermatofibroma  247, 248, 286 –  hemosiderotic  288 dermatofibrosarcoma  247 –  protuberans  288 dermatoglyphics  69 dermatoheliosis  166 dermatosis papulosa nigra  314, 322 dermoscopy/dermatoscopy  –  ABCD rule  19, 215 –  attachments  –  blood vessels  –  colors  –  equipment  –  machine vision computergenerated  218 –  score  19 desmoplasia  83, 159 digital camera  DNA –  nucleotide excision repair  166, 167 –  repair  187 dots  11 dysplastic nevus syndrome, see also familial atypical multiple mole melanoma syndrome  88, 144, 168 E endothelin-1  284 epidermal hyperplasia  155, 157 epidermolysis bullosa  30 epidermotropism  325 exophytic tumor  306 extravasated erythrocyte  131 F familial atypical multiple mole melanoma syndrome (FAMMM)  88, 168 familiar dysplastic syndrome  93 FAMMM, see familial atypical multiple mole melanoma syndrome fibrillar pattern  67, 72 fibrin  131 fibroblast  288 fibroplasia  31, 91 fibrosis  241, 261 fibroxanthoma  247 fissure  14 flat seborrheic keratosis  319 5-fluorouracil  167, 199, 300, 301 follicular cyst  286 G genital –  melanocytic nevus  119 –  melanoma  28, 229 –  melanosis  28 glabrous skin  197, 200 Glasgow 7-point checklist  global positioning radio system (GPRS)  58 globular pattern  17 globule  11 –  cobble-stone-like  110 GPRS, see global positioning radio system granularity  13 granuloma of pregnancy, see also pyogenic granuloma  305 H hairpin loop  209 halo –  nevus, see also albinismus perinaevicus, leukoderma acquisitum centrifugum, Sutton nevus  31, 124 –  phenomenon  126, 152 hemangioma  170, 224, 248, 284, 303, 310 hematoma –  subcorneal  309 –  subungual  308 hemoglobin  54 hemorrhage  308 hepatocyte growth factor/scatter factor (HGF/SF)  107 heterochromic melanonychia striata  173 HGF/SF, see hepatocyte growth factor/scatter factor Hochsteigerung  61 homogeneous pattern  17 HRAS –  amplification  152 –  mutation  152 Hutchinson’s –  melanotic freckle  233 –  sign  29, 173, 174, 198, 276 hyperchromatism  26 hyperkeratosis  208, 224, 251, 300 hypermelanotic nevus  93, 142 hyperpigmentation  147 hyperplasia  131, 175, 293, 322 hypertrichosis  108, 111 hypomelanosis  124 hypomelanotic melanoma  222, 239 hyponychial volar skin  198 hypopigmentation  205 hypopigmented nevus  287 I imiquimod  167, 300, 301 immersion technique  ink spot lentigo  225, 292 interferon alpha-2b  253 interleukin-2  253 in-transit metastasis  252 in-vivo confocal laser scanning microscopy  48 IR (near infrared) irregular crypt  181 irritated melanocytic nevus  129 K Kamino –  body  33, 159 –  nevus  82 keratin  210, 317 keratinization  299 keratinizing tumor  210 keratinocyte  40, 72, 135, 210, 295, 319 –  demarcation  42 keratoacanthoma  297, 299, 319 keratosis –  areola mammae  122 –  lichen planus-like  323 Subject Index L LAMB  80, 169 large blue-gray ovoid nest  14 laser Doppler flowmetry  49 lattice-like pattern  67 Laugier-Hunziker syndrome  199, 272 leaf-like area  14 lense  lentigines, see also lentigo simplex  175, 272, 290 lentigo –  maligna  233, 236, 238, 265, 293, 316 – – melanoma  166, 188, 267 – – progression model  234 –  senilis, see also actinic lentigo  236 –  simplex, see also lentigines 103, 136, 290 LEOPARD syndrome  169 leptomeninges  107 lesion asymmetry parameter  55 leukoderma  108, 125 –  acquisitum centrifugum, see also halo nevus  124 level of evidence  49 lichen  –  atrophicus  119 –  planus-like keratosis  323 –  sclerosus  30, 119 lipoma  170 liposarcoma  108 liquid nitrogen cryotherapy  235 Lisch nodule  167, 168 liver spot (see actinic lentigo)  293 lymphangiogenesis  251 lymphangitis  239 lymphoma  315 M macrophages  126 MAP-kinase (MAPK) pathway  107 MDP, see melanocytic differentiation pathway MED, see minimal erythema doses MelaFind  52 –  dermoscopic image  54 melanin  9, 11, 29, 54, 69, 284, 299, 325 –  caps  40 –  deposits in the brain  114 –  granules  73 –  loss  207 –  pigmentation  130, 204, 279 melanocortin-1 receptor gene  187 melanocyte  24, 26, 29, 106, 120, 135, 145, 149, 159, 215, 262, 319 –  the CNS  165 in –  malignant neoplasm  229 –  necrosis  219 –  nevus – – axilla  121 – – on the vulva  121 – – umbilicus  121 –  proliferation  28 –  stimulation  284 –  suprabasal  131 melanocytic –  differentiation pathway (MDP)  106 –  hyperplasia  246 –  nevus  71, 246, 319 – – nail apparatus  174 – – specific syndromes  164 –  tumor  149 –  non-melanocytic lesion algorhithm  16 melanocytosis  107 melanoma  64, 69, 82, 98, 108, 130, 286 –  amelanotic  206 –  asymmetry  244 –  atypical  211 –  balloon-cell  26 –  black patients  136 –  blood markers  253 –  blotch  245 –  blue-white veil  245 –  childhood  160 –  clinical recognition  –  desmoplastic  26 –  diagnosis  25 –  early stages  213 –  epidemiology  185 –  false negative  221 –  feature-poor  225 –  histopathological features  24 –  hypopigmented  206 –  situ  95, 217 in –  the nail apparatus  270 in –  incidence  185 –  incognito  222 –  latitude  188 –  lentigo maligna  233, 265 –  metastases  260 –  migration  189 –  minimal deviation  31 –  mortality  186 –  myxoid  26 –  nevi  187 331 –  nodular  –  occupational exposures  189 –  the trunk  238 of –  the vulva  229, 231 of –  partially pigmented  206 –  prevention  190 –  screening  250 –  skin colour  186 –  small-diameter  213 –  spitzoid  224, 226 –  streaks  245 –  exposure  188 sun –  symmetry  244 –  three Cs  melanonychia  29 –  striata  173, 174, 176, 270, 276 melanophage  82, 83, 323,325 melanosis  28  –  Dubreuilh  233 of melanosome  135, 284 melanotic macule  230 melphalan  262 MELTUMP  23, 92 Menzies method  20, 21, 244 Merkel cell carcinoma  247 Meyerson phenomenon  315 Meyerson‘s nevus  129–131 micro-capping  159 microvesiculation  131 Miescher nevus  139, 181 milia-like cyst  13, 111, 317 milkline nevus  119, 122 minimal erythema doses (MED)  130 Mohs micrographic surgery  235 mongolian spot  79, 80 moth-eaten garment  14 multicomponent pattern  17 multiple –  blue-gray globule  14 –  dysplastic nevus  222, 224 multispectral –  imaging  52 –  system  55 mycosis fungoides  315 myxoma  169 N nail –  matrix  176, 274 –  melanoma  270 –  nevus  173 NAME  80, 169 near infrared (IR)  52 neoangiogenesis  241 332 Subject Index neurocutaneous melanosis  108, 114, 115, 164 neurofibroma  167, 168 neurofibromatosis type I (NF-1), see also von Recklinghausen’s disease  167 neurotropism  26 nevoid –  cell  26 –  melanoma  131 nevus –  acquired  62 –  ancient  32 –  congenital  30, 61 –  dysplastic  42 –  growth  63 –  hypermelanotic  31 –  melanocytic  30 –  network  114 –  Ito  79 of –  midlife  142 of –  Ota  79 of –  outreach  114 –  particular pigmentation  142 –  recurrent (persistent)  32 –  spilus  109, 111 NF-1, see neurofibromatosis type I nodal metastasis  251 nodular melanoma  238, 242, 243, 266, 267, 315 non-edge papillae  44 N-RAS mutation  152 O onychomycosis  274 optic nerve glioma  168 optical coherence tomography  49 orthokeratosis  307 –  keratin layer  310 P pagetoid Spitz nevus  159 Paget’s disease  249 papillomatosis  322 parakeratosis  131, 156, 160, 299, 300 parallel –  furrow pattern  66, 67, 70, 71 –  pattern  17 –  ridge pattern  198 pattern analysis  17 Pautrier’s microabscess  30, 325 PCR analysis  252 PDA, see personal digital assistant pebbles on the ridges  69 penile melanosis  230 pepper-like granule  266 persistent nevus, see also recurrent nevus  147 personal digital assistant (PDA)  58 Peutz-Jeghers syndrome  199 pigment network  11 pigmentation –  drug-induced  175, 272 –  ethnic  175 –  the lunula  177 of pigmented –  actinic keratosis  225 –  basal cell carcinoma (BCC)  234, 246 – – telangiectasia  279 – – ulceration  279 –  genital lesion  119 –  parakeratosis  31 –  spindle cell nevus  33 pink nevus  142 PITSLRE gene  87 plasma hemoglobin  253 poikiloderma  166 polymorphism  187 polyvinyl chlorid  189 pregnancy  305 pruritus  108 psammomatous melanotic schwannomas  169 pseudo-colour image  48 pseudocomedos  13 pseudohorn cyst  208, 322 pseudo-Hutchinson’s sign  174, 178 pseudomelanoma  27 pseudonetwork  293, 298 pseudopod  12, 13, 245, 308 pyogenic granuloma, see also granuloma of pregnancy  24, 248, 273, 303–305, 315 R radial streaming  12 Raman spectroscopy  48 RCM, see reflectance-mode laser scanning confocal microscopy real-time videoconferencing  57 recurrent nevus, see also persistent nevus  147, 225 Reed nevus  33, 62, 63, 82151, 158, 159 reflectance mode laser scanning confocal microscopy (RCM)  39 regression  13 reticular –  depigmentation  153 –  pattern  17 reticulated lentigo  292 revised pattern analysis  17 rhabdomyosarcoma  106, 108 S SAMPUS  23, 92 satellite metastasis  240 satellitosis  240, 251 scale crust  131 scalp melanoma,  ABCDE criteria  265 schwannoma  32 sclerosing hemangioma  288 seborrheic keratosis  91, 97, 104, 111, 181, 183, 223, 234, 247, 248, 267, 313 –  Borst-Jadassohn appearance  322 segmentation  54 self-examination of the skin  5, 213 senescence  62 senile freckle, see also actinic lentigo  293 sentinel-lymph-node biopsy  252, 300 serum lactate dehydrogenase  253 seven-point checklist  20 SIAscope  52 sign of Leser-Trelat  315 skin –  fold freckling  168 –  pigmentation  135 –  self-examination  5, 213 –  sun-damaged  27 –  tumor – – two-step method  244 SkinCam system  49 solar –  elastosis  300 –  keratoses  188 –  lentigines  14, 318 –  lentigo, see also actinic lentigo  103, 293 speckled lentiginous nevus  109, 152 spectral analysis  48 SpectroShade  52 SPF, see sun protection factor spina bifida occulta  170 spinal dysraphism  170 Subject Index Spitz nevus  30, 33, 62, 75, 82, 97, 98, 120, 144, 208, 211, 224, 245, 247, 286 –  atypical  151 –  childhood  160 –  metastasizing  152 spitzoid melanoma  151 squamous cell carcinoma  246, 249, 296 –  the nail apparatus  273 of –  precursor lesions  295 SSM, see superficial spreading melanoma starburst pattern  17 stratum  –  corneum  7, 40, 73 –  granulosum  40 –  spinosum  40 strawberry pattern  298 streak  245 –  branched  12 stuccokeratosis  314, 322 Sturge-Weber syndrome  165 subcorneal hematoma  309 subungual –  hemorrhage  272, 308 –  melanoma  270 –  tumoral syndrome  273, 276 sulcus superficialis  68 sun –  exposure  188 –  protection factor (see SPF)  190 superficial spreading melanoma (SSM)  238, 239, 267 Sutton nevus, see also halo nevus  124, 129 T target globule  111 targeted-chemotherapy  254 targetoid hemosiderotic –  hemangioma  130 –  nevus  123, 129 TDS, see total dermoscopy score telangiectasia  282 teledermatology  57 –  mobile  58 teledermatopathology  58 teledermoscopy  9, 58 telomerase  87 telomere attrition  62 temozolamid  254 three-point checklist  21 total dermoscopy score (TDS)  20 traumatized nevus  129 Turner’s syndrome  125 Tyndall effect  78 typical nevus, see also common nevus  102 U ultra-violet index  186 Unna nevus  181 UV-irradiated nevus  129 333 V vaccine-based immunotherapy  254 vascular lesion  303 virtual slide system (VSS)  58 vitiligo  125 von Recklinghausen’s disease, see also neurofibromatosis type I  167 VSS, see virtual slide system vulvar –  melanosis  230 –  nevus  119 W web consultation  59 Wellman confocal criteria  43 white nevus  143 wireless local area network (WLAN)  58 WLAN, see wireless local area network wobble sign  181, 183 Wood’s light  3, 240 X xeroderma pigmentosum  166, 187 xerosis  108 XPD gene  187 .. .H.? ??P Soyer, G Argenziano, R Hofmann-Wellenhof, R. H Johr (Eds.) Color Atlas of Melanocytic Lesions of the Skin H.? ??P Soyer G Argenziano R Hofmann-Wellenhof R. H Johr (Eds.) Color Atlas of Melanocytic. .. basically as an atlas entitled Color Atlas of Melanocytic Lesions of the Skin and focuses on the morphologic dimension of melanocytic skin lesions It encompasses all the classical methods of morphology... such is not the case, the lesion has to be evaluated for the presence of arborizing blood I.3.6  Differential Diagnosis of Pigmented Lesions of the Skin The Board of the Consensus Netmeeting agreed