Authored by: Maggie Oliviero
|Description||This chapter describes the dermoscopyThe examination of [skin lesions] with a 'dermatoscope'. This traditionally consists of a magnifier (typically x10), a non-polarised light source, a transparent plate and a liquid medium between the instrument and the skin, and allows inspection of skin lesions unobstructed by skin surface reflections. Modern dermatoscopes dispense with the use of liquid medium and instead use polarised light to cancel out skin surface reflections. criteriameasure of how well one variable or set of variables predicts an outcome of lesions of the faceis a central body region of sense and is also very central in the expression of emotion among humans and among numerous other species.|
|Responsible author||Maggie Oliviero → send e-mail|
|Status update||May 29, 2017|
|Status by||Ralph P. Braun|
- 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 histologyThis glossary term has not yet been described. that affects the typical patternsThis glossary term has not yet been described. displayed by the same lesion on other areas of the body.
MalignantThis glossary term has not yet been described. non-melanocyticThis glossary term has not yet been described. neoplasms of the face
Basal cell carcinomas and squamous cell carcinomas are two of the most common malignantThis glossary term has not yet been described. non-melanocytic facial neoplasms. The clinical manifestations of these lesions are the same as they are on other anatomical body sites.
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-pigmentedThis glossary term has not yet been described. BCC include pink white areas; serpentine branched vesselsarborizing vessels Bright red sharply in focus large or thick diameter vessels dividing into smaller vessels BCC; shiny white structuresThis glossary term has not yet been described.; and areas of erosions/ulcerations.Pigmented BCC dermoscopically may display one or more of the following features: leaf-like structuresThis glossary term has not yet been described.; 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 networkThis glossary term has not yet been described.; serpentine branched vessels; areas of erosions/ulcerations; pink-white areas; and shiny white structures. .
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: vesselsThis glossary term has not yet been described. appearing as red dotsDots are small, round structures of less than 0.1 mm in diameter that have a red color when corresponding to blood vessels; however, when due to melanin, their color ranges from black, brown, to blue-gray depending on the depth and concentration of the melanin in the skin (Tyndall effect)., coiled, twisted looped, or surrounded by a halo; keratin linesstreaksThis glossary term has not yet been described.; 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 arrangementThis glossary term has not yet been described.; brown or gray dots, circles or oval structures in a linear arrangement; structureless zones; and shiny white structures. 
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 pseudonetworkA structureless pigment area interrupted by non-pigmented adnexal openings 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 keratosisActinic keratosis (also called solar keratosis and senile keratosis; abbreviated as AK) is a pre-cancerous patch of thick, scaly, or crusty skin.. They are characterized dermoscopically by an annular pattern (pseudonetwork); moth-eaten borders; gray dots/granules; white circlesThis glossary term has not yet been described.; rosettesFour bright white dots or clods arranged together as a square (or a four leaf clover); inner gray halo; evident follicles; and an associated red pseudo network; and a ‘dermoscopic’ scale. 
Manifestations of Facial Sebaceous Hyperplasia
The lesions present clinically as single or multiple, soft, yellow-white 2-4 mm papules.
Demoscopically sebaceous hyperplasiaThis glossary term has not yet been described. display yellow to yellow-white lobular structures; crown vesselsRadial serpentine or arborizing vessels at the periphery of the lesion that radiate towards the center but do not cross the midline od the lesion. sebaceous hyperplasia or linear winding serpentine vesselslinear irregular vessels with multiple bends. Seen with flat BCC and melanoma 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 lentiginesThis glossary term has not yet been described., seborrheic keratosesThis glossary term has not yet been described. 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 colorColor (American English) or colour (Commonwealth English) is the characteristic of human visual perception described through color categories, with names such as red, yellow, purple, or blue. 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 (fingerprintinglines brown curved parallel thin). The borders are sharp and/or moth-eaten. 
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 lentiginesThis glossary term has not yet been described. with the addition of fine interrupted lines that have become thicker; bulbous projections and ridgeThis glossary term has not yet been described. formation (gyri); a few milia cysts (shiny white circles); and comedo-like openings[[Comedo like openings]] (cryptsKeratin filled invaginations that are larger than comedo- like openings Moth eaten border Border with concave or sharp punched-out invaginations). A more evolved lesion (elevated lesion) will have the same dermoscopic features as a typical seborrheic keratosisThis glossary term has not yet been described. found on other anatomic sites: sharply demarcated borders, milia-like cystsThis glossary term has not yet been described., comedo-like openings, ridges, fissures, and hairpin vessels surrounded by a halo.squamous cell carcinomaThis glossary term has not yet been described., basal cell carcinomais the most common skin cancer, and one of the most common cancers in the United States. While BCC has a very low metastatic risk, this tumor can cause significant disfigurement by invading surrounding tissues, and melanomaThis glossary term has not yet been described. warrants the term ‘great masquerader.’ A separate chapter has been devoted to this neoplasm.
Manifestations of MelanocyticThis glossary term has not yet been described. neviThis glossary term has not yet been described.
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 neviis a type of melanocytic nevus (or mole) found in infants at birth. This type of birthmark occurs in an estimated 1% of infants worldwide; it is located in the area of the head and neck 15% of the time. 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 neviis a type of melanocytic nevus (or mole) found in infants at birth. This type of birthmark occurs in an estimated 1% of infants worldwide; it is located in the area of the head and neck 15% of the time. 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.NeviThis glossary term has not yet been described. 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 neviThis glossary term has not yet been described.. Dermoscopically these neoplasms display the same characteristics as on other anatomic sites, a globular homogeneous patternA pattern lacking any definable pigment structures, structureless pattern. One exception are intradermal nevi that are pale, flesh-tone papules with serpentine vessels. These lesions may mimic basal cell carcinomas. The blue nevusis a type of melanocytic nevus that clinically and dermoscopically will appear blue 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 diagnosisis the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines with variations in the use of logic, analytics, and experience to determine "cause and effect". In systems engineering and computer science, it is typically used to determine the causes of symptoms, mitigations, and solutions of melanoma on sun-damaged skinThis glossary term has not yet been described.” The diagnosis of melanoma on sun-damaged skin is challenging, since there are many neoplasms that may mimic this cancer, including lichen planusThis glossary term has not yet been described.-like keratosis (LPLKThis glossary term has not yet been described.), pigmented basal cell carcinomaThis glossary term has not yet been described. (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.
- Giacomel & Zalaudek: Dermoscopy of superficial basal cell carcinoma. Dermatol Surg 2005;31:1710-3. PMID: 16336893.
- Menzies et al.: Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000;136:1012-6. PMID: 10926737.
- Suppa et al.: Dermoscopic variability of basal cell carcinoma according to clinical type and anatomic location. J Eur Acad Dermatol Venereol 2015;29:1732-41. PMID: 25627865. DOI.
- Altamura et al.: Dermatoscopy of basal cell carcinoma: morphologic variability of global and local features and accuracy of diagnosis. J. Am. Acad. Dermatol. 2010;62:67-75. PMID: 19828209. DOI.
- Zalaudek et al.: Pitfalls in the clinical and dermoscopic diagnosis of pigmented actinic keratosis. J. Am. Acad. Dermatol. 2005;53:1071-4. PMID: 16310072. DOI.
- Rosendahl et al.: Dermoscopy of squamous cell carcinoma and keratoacanthoma. Arch Dermatol 2012;148:1386-92. PMID: 22986634. DOI.
- Zalaudek et al.: Dermoscopy in general dermatology. Dermatology (Basel) 2006;212:7-18. PMID: 16319467. DOI.
- Cameron et al.: Dermatoscopy of pigmented Bowen's disease. J. Am. Acad. Dermatol. 2010;62:597-604. PMID: 20079953. DOI.
- Chung et al.: Pigmented solar (actinic) keratosis: an underrecognized collision lesion. J. Am. Acad. Dermatol. 2013;68:647-53. PMID: 23261547. DOI.
- Nascimento et al.: Inner gray halo, a novel dermoscopic feature for the diagnosis of pigmented actinic keratosis: clues for the differential diagnosis with lentigo maligna. J. Am. Acad. Dermatol. 2014;71:708-15. PMID: 24947988. DOI.
- Mehregan et al.: Large cell acanthoma. Int. J. Dermatol. 2003;42:36-9. PMID: 12581141.
- Laur et al.: Lichen planus-like keratosis. A clinicohistopathologic correlation. J. Am. Acad. Dermatol. 1981;4:329-36. PMID: 7217401.
- Goldenhersh et al.: Documented evolution of a solar lentigo into a solitary lichen planus-like keratosis. J. Cutan. Pathol. 1986;13:308-11. PMID: 3771875.
- Watanabe et al.: Chronology of lichen planus-like keratosis features by dermoscopy: a summary of 17 cases. Dermatol Pract Concept 2016;6:29-35. PMID: 27222769. DOI.
- Zalaudek et al.: Using dermoscopic criteria and patient-related factors for the management of pigmented melanocytic nevi. Arch Dermatol 2009;145:816-26. PMID: 19620566. DOI.