- 1 Malignant non-melanocytic neoplasms of the face
- 2 Benign non-melanocytic neoplasms of the face
- 2.1 Sebaceous hyperplasia
- 2.2 Solar lentigines, seborrheic keratoses and lichen-planus like keratoses
- 3 Manifestations of Melanocytic nevi
- 4 Malignant pigmented melanocytic neoplasms of the face
Facial lesions are challenging to diagnose for many reasons, including the unique histology that affects the typical patterns displayed by the same lesion on other areas of the body.
Malignant non-melanocytic neoplasms of the face
Basal cell carcinomas and squamous cell carcinomas are two of the most common malignant non-melanocytic facial neoplasms. The clinical manifestations of these lesions are the same as they are on other anatomical body sites.
Manifestations of Facial BCC
Clinically BCC may appear as flat pink macules or papules, pearly lesions, rodent ulcers, cystic papules, white scar-like macules, or pigmented papules.
Dermoscopically, the characteristics of non-pigmented BCC include pink white areas; serpentine branched vessels; shiny white structures; and areas of erosions/ulcerations.
Pigmented BCC dermoscopically may display one or more of the following features: leaf-like structures; multiple non-aggregated blue-gray dots or blue globular structures; spoke-wheel-like structures or concentric structures; brown dots in-focus; absence of a pigmented network; serpentine branched vessels; areas of erosions/ulcerations; pink-white areas; and shiny white structures. .
Manifestations of Facial SCC
Clinically SCC present as pink papules, plaques or nodules that are smooth, hyperkeratotic or ulcerating.
Dermoscopically, non-pigmented SCC may display one or more of the following structures: vessels appearing as red dots, coiled, twisted looped, or surrounded by a halo; keratin lines; scale; blood spots; shiny white structures; and white circles with a central yellow plug.
Pigmented SCC dermoscopically display vessels appearing as red dots, coiled, or vessels in a linear arrangement; brown or gray dots, circles or oval structures in a linear arrangement; structureless zones; and shiny white structures. 
Manifestations of Facial AK
Actinic keratoses, both pigmented and non-pigmented, considered by some to be insipient squamous cell carcinomas, are also common on the sun-exposed skin of the face.
Actinic keratoses clinically are characterized by rough, scaly 2-10mm pink to red macules and patches.
Dermoscopically non-pigmented actinic keratoses display a white to yellow surface scale; erythema with a pink to red pseudonetwork surrounding the hair follicles; fine, linear wavy vessels surrounding the follicular openings; and follicles with yellowish keratotic plugs and/or surrounded by a white halo.
Pigmented actinic keratoses are collision tumors, a lentigo with an overlying actinic keratosis. They are characterized dermoscopically by an annular pattern (pseudonetwork); moth-eaten borders; gray dots/granules; white circles; rosettes; inner gray halo; evident follicles; and an associated red pseudo network; and a ‘dermoscopic’ scale. 
Benign non-melanocytic neoplasms of the face
is a common benign condition of adults beginning at middle age.
Manifestations of Facial Sebaceous Hyperplasia
The lesions present clinically as single or multiple, soft, yellow-white 2-4 mm papules.
Demoscopically sebaceous hyperplasia display yellow to yellow-white lobular structures; crown vessels or linear winding serpentine vessels at the periphery of the lesion that radiate toward the center. Alternate names for the vessels include wreath or crown vessels.
Dermatoscopic and clinical criteria of pigmented non-melanocytic neoplasms: benign.
Solar lentigines, seborrheic keratoses and lichen-planus like keratoses
are common benign non-melanocytic pigmented lesions present on the face. Due to the fundamental histologic anatomy of the face, adnexal structures and epidermal thinning due to years of UV exposure, the neoplasms display patterns that may differ from the same lesion found on other anatomic sites.
Manifestations of Facial Solar Lentigines
Clinically the lesions appear as small, well circumscribed, pigmented macules. Histologic findings may include hyperplasia of the epidermis and increased pigmentation of the basal layer. A variable number of melanocytes are present and may be increased in number; however, they do not form nests. Pigmentation may be homogeneous or variegated, with color ranging from brown to black.
Dermoscopically two patterns, an annular and reticular pattern may be visualized. An annular pattern (pseudonetwork) is characterized by small circles (follicular openings) surrounded by light brown to dark brown pigmentation. Whereas a reticular pattern features fine lines, which may be curved, straight, and interrupted (fingerprinting). The borders are sharp and/or moth-eaten. 
Manifestations of Facial Seborrheic keratoses
Seborrheic keratoses clinically appear as round or oval smooth, waxy or scaly flesh colored, tan, brown, or black papules 1-2.5 cm in size. As lesions evolve they have a “stuck-on” appearance.
Dermoscopically early seborrheic keratoses (flat lesions) share the characteristics of solar lentigines with the addition of fine interrupted lines that have become thicker; bulbous projections and ridge formation (gyri); a few milia cysts (shiny white circles); and comedo-like openings (crypts). A more evolved lesion (elevated lesion) will have the same dermoscopic features as a typical seborrheic keratosis found on other anatomic sites: sharply demarcated borders, milia-like cysts, comedo-like openings, ridges, fissures, and hairpin vessels surrounded by a halo.
Manifestations of Lichen planus-like keratoses
Lichen planus-like keratoses that appear on the face, clinically and dermoscopically display the same characteristics as LPLKs on other anatomic sites. As the lesions may mimic malignancies such as squamous cell carcinoma, basal cell carcinoma, and melanoma warrants the term ‘great masquerader.’ A separate chapter has been devoted to this neoplasm.
Manifestations of Melanocytic nevi
Common melanocytic nevi often measure less than 6 mm to 10 mm, with smooth and regular borders. Relative to size and elevation, common acquired nevi can present as pigmented pale flesh-tone, tan to light brown, brown to brownish-black macules, papules and nodules. Congenital nevi are present at birth and result from a proliferation of benign melanocytes in the dermis, epidermis, or both. Occasionally, nevi that are not present at birth but are histologically identical to congenital nevi may develop during the first 2 years of life. They are referred to as congenital nevus tardive. Blue nevi appear as flat to slightly elevated, smooth surfaced macules or papules that are gray-blue to bluish black in color. Lesions are usually solitary.
Nevi that are flat are characterized dermoscopically with an annular pattern. The circles (follicular openings) tend to have the same size and shape, with uniform pigmentation and display a relatively symmetric pattern. However, the most common nevi on the face are intradermal nevi. Dermoscopically these neoplasms display the same characteristics as on other anatomic sites, a globular homogeneous pattern. One exception are intradermal nevi that are pale, flesh-tone papules with serpentine vessels. These lesions may mimic basal cell carcinomas. The blue nevus dermoscopically presents as a homogeneous blue, blue-white, dark purple macule or papule. 
Malignant pigmented melanocytic neoplasms of the face
“One of the most important roles for dermoscopy of facial lesions remains the early diagnosis of melanoma on sun-damaged skin” The diagnosis of melanoma on sun-damaged skin is challenging, since there are many neoplasms that may mimic this cancer, including lichen planus-like keratosis (LPLK), pigmented basal cell carcinoma (BCC), and pigmented actinic keratosis (PAK). Special attention should be given to isolated pigmented lesions (to one facial quadrant) acquired during adulthood. In addition, knowing the dermoscopic features of facial neoplasms, including melanoma-specific facial features, can aid in the differentiation between melanoma simulators and melanoma. The features of melanoma will be discussed in a separate chapter.
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