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GENERAL INSTRUCTIONS

General Instructions

  • For each case, there is a short history along with a clinical and an unmarked dermoscopic image.

  • Study the unmarked dermoscopic image and try to identify the global and local dermoscopic features.

  • Make your diagnosis.

  • Next, turn the page and the dermoscopic image will be presented again, this time marked with all the salient dermoscopic findings.

  • On the same page you will also find the diagnosis along with a detailed discussion and a few pearls for your review.

CASE 1

CASE 1 HISTORY

This 88-year-old woman has a biopsy-proven basal cell carcinoma under a dark plaque. Clinically, both lesions seem to be connected.

DERMOSCOPIC CRITERIA

  • Round follicular openings (yellow arrows)

  • Asymmetrical follicular pigmentation (white arrows)

  • Rhomboid structures (yellow box)

  • Irregular blotch with follicular openings (white box)

  • Irregular blotch without follicular openings (stars)

  • Irregular dots and globules (yellow circles)

  • Milky-red areas (black arrows)

DIAGNOSIS:

Lentigo Maligna Melanoma

DISCUSSION

  • Asymmetrical follicular pigmentation, rhomboid structures, annular-granular structures, and circle within a circle are the main criteria associated with melanoma on the face.

  • Asymmetrical follicular pigmentation can also be seen in pigmented actinic keratosis and pigmented Bowen disease.

  • The first step in the progression of melanoma on the face is represented by asymmetrical follicular pigmentation.

  • The follicular openings should not be confused with milia-like cysts seen in seborrheic keratosis.

  • The next step in the progression of melanoma on the face is the formation of rhomboid structures.

  • True rhomboid forms (parallelogram with unequal angles and sides) are not necessary to identify.

  • Any pigmented thickening that completely surrounds follicular openings should be considered rhomboid structures.

  • The irregular black blotch with follicular openings is the first sign of dermal invasion (lentigo maligna melanoma).

  • The irregular black blotch without follicular openings represents complete obliteration of follicular openings, indicating further dermal invasion.

PEARLS

  • This is a collision tumor, representing a basal cell carcinoma and melanoma.

  • The diagnosis of melanoma on the face is not always this easy.

  • It is essential to learn the definitions of the 4 main criteria associated with melanoma on the face and be able to recognize them.

  • Dermoscopy is essential to help make the diagnosis in most cases of early lentigo maligna and offers patients their best chance for survival.

CASE 2

CASE 2 HISTORY

This lesion had been ignored for many years. Itch was the reason the patient finally went to see his family physician, who referred him to a dermatologist for evaluation.

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