Dermoscopic structures (full text)

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Pigment Network[edit]

The pigment network consists of a grid of intersecting pigmented “lines” forming a honeycomb pattern [1]. The anatomic basis of the pigment network is melanin in keratinocytes or in melanocytes along the DEJ, representing the way the rete ridge pattern of the epidermis appears when viewed in the horizontal plane. The less-pigmented “holes” of the network correspond to tips of the dermal papillae and the overlying suprapapillary plates of the epidermis [2]. A wide diameter of dermal papillae would correspond dermoscopically to wider network “holes,” whereas narrow dermal papillae would result in a denser sieve of the grid. The pigment network in melanocytic lesions is further characterized as typical or atypical.

Network schematic-42.jpg

Typical network[edit]

The typical network is regularly meshed and composed of lines that are relatively uniform in width and homogenous in color; the lines often become gradually thinner and fainter in pigmentation at the lesion’s periphery:

Network schematic.jpg

An example of a typical pigment network clinically and dermoscopically:

Reguler network.jpg

On histopathology, the lines of the typical network correspond to pigment in the rete ridges, that are relatively uniform in width and equidistant from each other.

Histology network.jpg

The typical network usually corresponds to the junctional component of a nevus. However, reticulation can also be seen in darkly pigmented normal skin and in heavily pigmented rete ridges as encountered in dermatofibromas, ink spot lentigo or accessory nipples [3].

Atypical network[edit]

The atypical network is irregularly meshed with lines that vary in width and degree of pigmentation and with “holes” that are heterogeneous in area and shape. An atypical network shows foci with broader and darker pigmented lines; the network often ends abruptly at the lesion’s periphery. An atypical network within a lesion may also appear perturbed and broken up, a finding referred to as “branched streaks”.

Atypical network31.jpg

An example of an atypical pigment network clinically and dermoscopically:

Atypical network.jpg

On histolopathology, the irregular lines of an atypical network correspond to variation in the width, length, and spacing of the rete ridges due to variation in the size, spacing, and tendency to confluence of melanocytic nests. Rete ridges that are elongated and widened by larger junctional nests of melanocytes would appear as darker and wider lines on dermoscopy [4]. The atypical network is often seen in melanoma and dysplastic nevi [1] .

Pseudonetwork[edit]

The anatomy of the rete ridge pattern of the face differs from that of non-facial skin, and is usually flatter. Accordingly, the pigment network is usually absent in these locations and is replaced by a pseudonetwork pattern. The "holes" in the pigmented epidermis correspond histologically to adnexal openings, such as sebaceous glands, hair follicles or sweat glands.

A pseudonetwork sketch:

Pseudonetwork schematic 23.jpg

Clinical and dermoscopic images of pseudonetwork:

Nevus face.jpg

Histologically, adnexal openings are responsible for the "holes" in the pigment reticulation:

Histology nevus face.jpg

Structureless Areas[edit]

Areas within a lesion that are devoid of any network or other structures, such as globules or regression structures (i.e., scars, peppering, granularity, or blue-white veil over flat areas), are called “structureless areas”. Their size should be at least 10% of the lesions's total surface area. Structureless areas can be hypopigmented, hyperpigmented or regularly pigmented.

Hypopigmented structureless areas[edit]

Hypopigmented structureless areas have a lighter pigment compared with the rest of the lesion; however, they manifest the same or slightly more pigment compared with the surrounding normal skin (N.B.: structureless areas that are hyperpigmented are called blotches). Focal structureless areas within a lesion are a common finding in nevi.

Nevus central hypopigmentation.jpg

In contrast, focal tan to light brown structureless areas at the periphery of a melanocytic lesion is commonly associated with melanoma. Peripherally located structureless areas in melanoma tend to have a light brown to fawn color and tend to end abruptly at the edge of a lesion. Histologically, these areas are characterized by flattening of the DEJ (loss of the undulating pattern of rete ridges and dermal papillae) and scattering of atypical melanocytes in suprabasal epidermal layers (i.e., pagetoid cells).

Melanoma displaying tan structuresless area


Hyperpigmented structureless areas (Blotches)[edit]

A blotch is defined as an area with a size that is at least 10% of the lesion’s surface area and is heavily pigmented. In a blotch the melanin pigment is often present throughout the skin, including the stratum corneum, epidermis, and the dermis [5]. The dark pigment in a blotch visually obscures the ability to discern any underlying structures [6]. Blotches can be regular or irregular.

Regular hyperpigmented structureless area (Blotch)[edit]

Peripheral reticuler central hyperpigmentation schematic.jpg

Regular blotches are defined as those that display symmetry, regular borders,homogenous dark hue, and are located within the center of the lesion. A pigment network often surrounds a regular blotch. Regular blotches are associated with nevi.

Regular blotch.jpg

Regular blotches can be seen in “activated” nevi and are attributed to heavy melanin concentrations in the stratum corneum. Because the pigment is concentrated in the stratum corneum, it can easily be stripped off using a tape-stripping procedure, thereby revealing underlying structures.


Irregular hyperpigmented structureless area (Blotch)[edit]

Irregular blotches are defined as those that are asymmetric, have irregular contours, are located off center, and/or display multiple dark hues (i.e., heterogenous dark hues). Irregular blotches are associated with melanoma or dysplastic nevus.

Atypical blotch 37.jpg
Irregular blotch.jpg
Irregular blotch histopathology.jpg

Homogenous blue pattern[edit]

Homogenous blue pattern (structureless blue) is characterized by the presence of blue color with the absence of other dermoscopic structures throughout the entire lesion [6]. Histologically, it corresponds to densely pigmented melanocytes or melanophages in the dermis. Dermoscopic differential diagnosis is broad and includes blue nevi, combined nevi, areas of extensive regression, pigmented nodular melanoma, primary or metastatic melanoma, BCC and radiation tattoos [7][8].

Dots[edit]

Dots are small, round structures of less than 0.1 mm in diameter (similar to the diameter of a terminal hair follicle) [6] that correlate with blood vessels or melanin pigment. When blood vessels appear as dots, their color is red; however, when the underlying structure is melanin, their color ranges from black, brown, to blue-gray depending on the depth and concentration of the melanin in the skin (Tyndall effect). Black dots are often due to melanin pigment accumulation in the stratum corneum, but can also be due to vertical stacking of pigment within the epidermis or due to heavy aggregates of melanin in small clusters of melanocytes or keratinocytes located in the upper layers of the epidermis (just below the stratum corneum). Black dots that are in the stratum corneum are usually found overlying the grid lines of the pigmented network and they can easily be tape stripped off the skin. Brown dots are often associated with focal melanin accumulations at the DEJ or spinous layer and they usually correspond histologically to small junctional melanocytic nests. The dots, resulting from nevus nests located at the tips of rete ridges, tend to be situated overlying the network lines. Less frequently, brown dots correspond to melanocytic nests located in the skin below the stratum corneum or even within the stratum corneum. The nests present within the stratum corneum are probably in the process of being extruded from the skin via trans-elimination. Brown dots corresponding to small melanocytic nests situated in the papillary dermis appear as dots situated within the holes of the network. These so-called target networks with dots/globules or halo dots/globules are a common finding in congenital melanocytic nevi. Although on rare occasions brown dots can be tape stripped off the skin, most brown dots cannot be removed via tape stripping. Black or brown dots may appear after acute ultraviolet exposure; however, these dots tend to disappear over time. It is interesting to note that many non–ultraviolet-induced dots that are successfully tape stripped off the skin reappear with time.

Gray-blue dots (also called granules or peppering) are due to fine melanin particles within melanophages or as extracellular “dust” in the superficial dermis; this feature is associated with regression.

Dots 28.jpg




Regular dots[edit]

Dots clustered at the center of the lesion, or located on the network lines (also called target network)

Regular dots 24.jpg
Dots.jpg

Irregular dots[edit]

Irregular dots tend to be heterogenous in size, shape and color and are frequently found at the periphery of a given lesion or scattered throughout the lesion.

In melanomas, dots are irregularly distributed and may be found focally at the periphery of lesions. Blue-gray dots can also correspond with small dermal aggregates of pigmented BCC. Red dots are equivalent to dotted vessels and can be seen in diverse cutaneous tumors such as keratinocyte carcinomas, Spitz nevi and melanomas [9].

Dots schematic 24.jpg

Globules[edit]

Globular pattern schematic.jpg
Globules26.jpg

Globules are symmetrical, round to oval, well-demarcated structures with a diameter that is larger than 0.1 mm. They usually correspond to nests of pigmented benign or malignant melanocytes situated in the lower epidermis, at the DEJ, or in the papillary dermis. On occasion globules may correspond to large clumps of melanin, melanophages, or pigmented milia cysts. Like dots, the color of globules may be brown, black, blue-gray, or red. The significance of these colors is the same as discussed for dots. White globules correspond to melanocytes undergoing balloon cell changes [10].

Both dots and globules may occur in nevi as well as in melanoma. In nevi, the globules are uniform in size, shape, and color (mostly brown), and are either: (1) evenly distributed in the lesion; (2) mostly present at its center, surrounded by a network; (3) uniformly distributed throughout the nevus; or (4) circumstantially along the entire perimeter of the nevus, which correspond to a horizontal growing phase, that can occur either in a growing nevus or in a superficial spreading melanoma.

Globules.jpg
Globules histology.jpg

In melanomas, globules and dots vary in size, shape, and color, are unevenly distributed in the lesion, and are frequently found focally at the periphery of lesions [8]. Because both dots and globules frequently correlate with nests of melanocytes, they are often described for simplicity and reproducibility as a combined term “dots and globules”.

Irregular globules and dots.jpg



However, irregular pigmented globules located eccentrically at the periphery of a raised, otherwise homogeneous melanocytic lesion may raise suspicion for a BAP1-inactivated melanocytic tumor (BIMT), also known as Wiesner nevus or “bapoma” [11]. BIMT are a special subset of melanocytic lesions which have two components histologically: a more banal-looking population which corresponds to the globular component located at the periphery, plus an atypical spitzoid population which has a loss of expression of BAP1 and corresponds to the homogenous area of the lesion. Multiple BIMT have been associated with a cancer syndrome with increased risk for uveal melanoma, cutaneous melanoma, mesothelioma, renal cell carcinoma, among others [12][13].

Streaks[edit]

Streaks are linear pigmented projections seen at the periphery of lesions. Both pseudopods (streaks with bulbous projections at their tips) and radial streaming (streaks without bulbous projections at their tips) are considered to be streaks. Streaks in melanoma are usually observed only focally and asymmetrically at the lesion’s periphery and reflect the radial growth phase of the tumor. On the other hand, streaks that are distributed symmetrically around the entire perimeter of the lesion are seen mostly in pigmented spindle cell nevi (Spitz or Reed) [14].

Streaks schematic 25.jpg

Histologically, streaks represent confluent junctional nests of melanocytes [9]. Pseudopods are finger-like projections of dark pigment (brown to black) at the periphery of the lesion. They have small knobs at their tips, and are connected to either a central pigment network or central pigmented blotch. To be considered pseudopods the bulbous knobs must have a maximum diameter that is larger than the network from which it originates. Menzies and colleagues found pseudopods to be one of the most specific features of superficially spreading melanoma [15]. On histopathology, pseudopods correspond to junctional confluent nests of melanocytes at the periphery of the lesion. Confluence of nests is also a criterion in histopathology, typical for dysplastic nevi or malignant melanoma. Depending on which area of the pseudopod is sectioned on histology, the pathologist will see this structure either as a circular cluster of cells of varying diameters or as an oval-shaped cluster of cells. Only if the pathology section passes exactly through the longitudinal axis of a pseudopod will the pathologist be able to recognize this structure as an elongated tubular cluster of cells.

Pseudopod histology.jpg

Needless to say, the statistical probability of this happening is very low unless of course the pathologist uses dermoscopy at the grossing table to orient and oversee the step sectioning process. On occasion, peripheral globules and pseudopods can look similar to each other at first glance. However, with peripheral globules one will observe a small clear space separating the globule from the main tumor mass. These peripheral globules are presumed to correspond to junctional melanocytic nests at the tips of rete ridges and they are usually associated with growing/enlarging nevi. In contrast, pseudopods emanate from, and are directly connected to, the main tumor mass through a stalk. Radial streaming appears as radial parallel linear extensions at the periphery of the lesion. On histopathology, radial streaming also correlates with confluent junctional nests of pigmented melanocytes.

Regular streaks.jpg


Irregular pseudopods .jpg

Angulated lines[edit]

Angulated lines are geometrical lines in a zig-zag pattern, which may coalesce forming polygons. These structures are called rhomboids or zig-zag pattern [1] when observed in the face or neck and are associated with lentigo maligna (LM) [16] {{{authors}}}: {{{title}}}. {{{journala}}} {{{year}}};

). PMID: [1].. In other locations, the angulated lines appear to be larger than the rhomboids seen in LM and are highly suspicious of lentiginous melanomas from chronically sun-exposed skin [17]. Histologically, the polygonal nature of these lines is still unknown. However, angulated lines seem to correspond to a flattened dermoepidermal junction (DEJ) with fewer and more blunted rete pegs due to a proliferation of atypical melanocytes at the DEJ together with a focal accumulation of melanophages in the superficial dermis [18].
Angulated lines in melanoma

Negative Pigment Network[edit]

The “negative” of the pigmented network (also known as reverse or inverse network) consists of relatively lighter areas comprising the apparent grid of the network and relatively darker areas filling the apparent “holes”. The lighter grid lines tend to be serpiginous and the darker areas, when viewed in isolation, resemble elongated tubular or curved globules. Histopathologically, the negative network appears to correspond to thin elongated rete ridges accompanied by large melanocytic nests within a widened papillary dermis or to bridging of rete ridges. Although the negative network is highly specific for melanoma (95% specific), especially for a melanoma arising in a nevus {{{authors}}}: {{{title}}}. {{{journala}}} {{{year}}};

). PMID: [2]., it can also be found in some Spitz nevi and rarely in other nevi, such as congenital nevi {{{authors}}}: {{{title}}}. {{{journala}}} {{{year}}};
). PMID: [3].. In congenital nevi, the negative pigmented network is usually diffuse and symmetrical in its distribution. In contrast, the negative pigmented network seen in melanoma is often focal and asymmetrically distributed.
Negative network schematic 32.jpg
Negative network small.JPG

Shiny white structures[edit]

Bright, white, shiny appearing structures that are visible under polarized dermoscopy and can take on different morphologies, including: shiny white streaks, shiny white blotches and strands (shiny white areas), and rosettes [19]. Some authors don't make the distinction between them and refer to all of them as "shiny white structures".

Shiy white structures schematic 28.jpg

  • Shiny white streaks

Christalline structures are white shiny linear streaks that are seen under polarized dermoscopy, but not under nonpolarized dermoscopy. The white streaks are oriented parallel, and sometimes also orthogonal (perpendicular) to each other. Chrysalis structures can be seen in scars, dermatofibromas, basal cell carcinomas, and also in melanomas and Spitz nevi. These structures correlate histopathologically with altered collagen in the dermis (fibrosis). The birefringent properties of collagen bundles cause rapid randomization of polarized light. This is the reason collagen appears bright white and more conspicuous under polarized dermoscopy [20].

An example of shiny white lines as they appear in polarized (right image) as opposed to non-polarized dermoscopy (left image):

Npd vs pd blue veils.JPG


  • Shiny white blotches and strands / Shiny white areas

These are discrete, white shiny clods (blotches) or larger structureless areas or long thick or thin lines, randomly distributed or parallel, and not orthogonally oriented (Strands). Like shiny white streaks these structures have been associated with collagen alterations, such as fibrosis, in the underlying stroma [21].

  • Rosettes

Rosettes (also known as ‘four-clod dots’) are defined as four white points, arranged as a four leaf clover. They are not lesion-specific and are described in many tumoral and inflammatory lesions, including: scars, dermatofibroma, actinic keratosis, squamous cell carcinoma and melanoma and more. Smaller rosettes are mainly caused by polarizing horny material at infundibular level in adnexal openings and larger rosettes mainly by concentric perifollicular fibrosis [22].

Rosettes.jpg

Regression Structures[edit]

Regression structures appear dermoscopically as:

  • white scar-like depigmentation (lighter than the surrounding skin)
  • “peppering” (speckled multiple blue-gray granules)

On histopathology fully evolved regression shows fibrosis and melanosis (infiltrate of melanophages), and sparse lymphocytic infiltrates. The normal undulating DEJ pattern formed by rete ridges and dermal papillae is attenuated to completely Flattened. Regression structures consisting of both scar like depigmentation and peppering (granularity) should raise suspicion for melanoma. Regression structures consisting of only peppering can be seen in melanoma, lichen planus like keratosis and nevi. In lichen planus like keratosis the granularity tends to be coarse and diffusely distributed. In melanocytic lesions the granularity tends to be finer and focally distributed. These areas should not be chosen for sectioning when grossing a suspected melanoma as they may reveal non-diagnostic features or underestimate the Breslow thickness.

White scar-like depigmentation[edit]

corresponds to a white discoloration of the lesion, which is lighter than the surrounding normal skin. On histopathology, this dermoscopic structure correlates with fibrosis.

Scarlike depigmentation peppering 28.jpg
Scar like depigmentation.jpg

Granularity[edit]

Granularity (also known as “peppering”) is defined as accumulation of multiple very small (<0.1 mm), nondescript, blue-grey dots. If a large area shows dense, confluent granularity, it is difficult to distinguish from blue-white veil, however, clinically, granularity often is seen in macular portions of the lesion, while blue-white veil is seen in palpable areas. Histopathologically, granularity correlates with melanin in the superficial dermis, either as fine melanin particles in melanophages or extracellular “dust-like” particles. When granularity is encountered in nevi it tends to encompass less than 10% of the lesion’s surface area. In contrast, in melanoma the granularity often encompasses more than 50% of the lesion’s surface area.

Confluent peppering scarlike 27.jpg
Granularity also known as peppering



Blue-White Veil[edit]

Blue-white veil is confluent blue pigmentation with an overlying white “ground-glass” haze. In melanoma, the bluewhite veil does not occupy the entire surface area of the lesion, but rather is present as a focal, ill-defined area. Histopathologically, this dermoscopic structure corresponds to an aggregation of heavily pigmented cells (melanocytes and/or melanophages) or melanin in the dermis (blue color) in combination with compact orthokeratosis [23][9]. At times, it is difficult to distinguish between regression structures (namely melanosis) and blue-white veil by dermoscopy because both structures display blue-white color. However, examining the lesion without dermoscopy can help differentiate between blue-white color due to regression versus due to deep melanocytes. In regression the surface contour will be flat (macular) and in blue-white veil the surface will be raised and palpable. In melanoma the blue-white veil is nonuniform in color and is present focally within the lesion. In contrast, the blue-white veil has a uniform steel-blue color in blue nevi and it occupies the entire surface area of the lesion.

Blue whitish veil 26.jpg
Blue white veil.jpg

Vascular Structures[edit]

In recent years, more attention has been given to the vascular patterns of pigmented and nonpigmented lesions. The increased availability of dermoscopes using polarized light allow for the inspection of a lesion without the need to contact the lesion. This prevents blood vessel compression, which in part helps in making the blood vessel morphology more conspicuous. A detailed description of the vascular structures can be found here Vascular structures.

File 29.10.17, 19 44 37.jpeg

Milia-like Cysts[edit]

Milia-like cysts are round whitish or yellowish structures that are seen commonly, but not exclusively, in seborrheic keratosis under non-polarized dermoscopy. They can also be seen in melanocytic nevi, especially those with a congenital pattern. Sometimes milia-like cysts are pigmented and resemble globules. Milia-like cysts correspond to intraepidermal keratin horn pseudocysts [24].

Milia like cysts comedo like openings schematic new.jpg
Milia like cysts.JPG

Comedo-like Openings[edit]

Comedo-like openings are commonly seen in seborrheic keratosis and rarely in melanocytic nevi with a congenital pattern, such as papillomatous nevi and in melanoma [25]. They appear on dermoscopy as dark roundish structures, and clinically, can be appreciated as surface invaginations. Histopathologically, comedo-like openings correspond to the concave, keratin filled, invaginations of the epidermis [24].

Milia like cysts comedo like openings schematic new.jpg
Comedo like opening1.JPG

Fissures and Ridges (“Brain-like" or "Cerebriform Appearance”)[edit]

Fissures (invaginations or sulci) are commonly seen in seborrheic keratosis and may also be seen in melanocytic nevi with congenital pattern. In essence, fissures are linear grooves in the epidermis and, like comedo-like openings, correspond to surface invaginations. A pattern that resembles “brain-like appearance” or cerebriform appearance is created, with the grooves resembling “sulci” and the intervening ridges resembling surface“gyri” [6]. Fissures correspond histopathologically to wedgeshaped, keratin-filled invaginations of the epidermis [24].

Milia like cysts comedo like openings schematic new.jpg
Fissures and Ridges.JPG

Fingerprint-like Structures[edit]

Some flat seborrheic keratoses and solar lentigines can show tiny ridges running in parallel and producing a pattern that is reminiscent of fingerprints.

Untitled Artwork 24.jpg

Moth-eaten Border[edit]

Some flat seborrheic keratoses have concave borders so that the pigment ends with curved to semi-circular indentations, which has been compared to a moth-eaten garment.

Solar lentigo schematic 2.jpg

Leaf-like Areas[edit]

Leaf-like areas are seen as brown to gray-blue discrete bulbous blobs that often form a pattern shaped like a leaf. They can sometimes appear as tan, broad, and fuzzy streaks at the periphery of a lesion. In the absence of a pigment network, they are highly suggestive of pigmented basal cell carcinomas.

Histopathologically, they represent dermal nodular aggregates of pigmented basal cell carcinoma. [26]

Leaf like areas29.jpg
Concentric, leaf like.jpg

Spoke-wheel-like Structures[edit]

Spoke-wheel-like structures are well-circumscribed brown to gray-blue– brown radial projections that radiate out from a dark brown central hub. Sometimes the radial projections are not visible and instead one sees a concentric globule consisting of a round structure with a central darker hub, which is surrounded by a brown halo of pigment. In the absence of a pigment network, spoke-wheels are highly suggestive of basal cell carcinoma.

Histopathologically, they correspond to the nests of basal cell carcinoma emanating from the undersurface of the epidermis; a common finding in superficial basal cell carcinoma [26].

Spoke wheel schematic 27.jpg
BCC Pigmented Multiple Abdomen Derm 2.JPG

Large Blue-Gray Ovoid Nests[edit]

Ovoid nests are large, discrete, and well-circumscribed, pigmented ovoid areas, larger than globules. When a network is absent, ovoid nests are highly suggestive of basal cell carcinoma. Ovoid nests correspond on histopathology to dermal aggregates of pigmented basal cell carcinoma [26].

Blue gray ovoid nests and globules BCC schematic.jpg
Blue gray ovid nests.jpg

Multiple Blue-Gray Non-aggregated Dots and Globules[edit]

Multiple blue-gray dots and globules are round, discrete, and well circumscribed structures that, in the absence of a pigment network, are highly suggestive of a basal cell carcinoma. These dots and globules usually do not form aggregates as seen in melanocytic lesions. They correlate with dermal aggregates of pigmented basal cell carcinoma and are similar to ovoid nests, but smaller [26].

Blue gray ovoid nests and globules BCC schematic.jpg
Blue-gray globules &dots.jpg

Lacunae[edit]

Lacunae are multiple well-demarcated round/oval and reddish structures arranged in clusters, separated by a white rim called septae. Histologically, they correspond to dilated, thin-walled vessels in the papillary dermis. Lacunae are the hallmark of vascular tumors, mainly angiomas. Dark (violaceous, blue-black, or black) lacunae reveal partially or completely thrombosed dermal vessels located deeper in the dermis, which are very specific of solitary angiokeratomas [27]. In targetoid hemosiderotic angiokeratomas a central dark lacunae is surrounded by a peripheral red-brownish homogeneous area. Histopathologically, it reveals the presence of less dilated angulated vascular spaces, hemosiderin deposition and extravasated erythrocytes in the mid and deep dermis [28]

Lacunae 27.jpg
Lacunae.jpg

Podcasts[edit]



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