Mucosa

From dermoscopedia

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Despite their rarity, lesions in the mucosal areas got a challenging aspect.

They involve lips and oral cavity, perianal skinThis glossary term has not yet been described. and the genital skin of the penis and vulva (1–3). This special pattern of localization is explained by the histologyThis glossary term has not yet been described. of the mucosal area, lacking normal keratin and granular layer. Parakeratin can be seen on histological samples.

Mainly in the genital areas, we recommend to follow the suggestion of Dr. Alfred Kopf (personal communication) to cover the dermoscope with polyvinyl chloride film, in order to avoid the contamination of dermoscope. If the immersion liquid (e.g. disinfection spray, oil, water) is not placed on the side between the PVC film and lens of the dermoscope, the dermoscopic image cannot allow performing an accurate diagnostic.


DermoscopyDermoscopy is a non invasive diagnostic method. of oral lesions

Non-pigmentedThis glossary term has not yet been described. oral lesions

The dermoscopyDermoscopy is a non invasive diagnostic method. of non-pigmentedThis glossary term has not yet been described. oral lesions (Figure 1) are evidenced as proliferative (benignThis glossary term has not yet been described. and malignantThis glossary term has not yet been described.), inflammatory and autoimmune, infectiousThis glossary term has not yet been described. and anatomical variant of the lip.

BenignThis glossary term has not yet been described. non-pigmented oral lesions

  • The squamous benign papilloma represents a common intraoral benign neoplasia which displays white-pink cauliflower-like surface projections.
  • Venous lakes and angiomangiomas are benign tumors derived from cells of the vascular or lymphatic vessel walls (endothelium) or derived from cells of the tissues surrounding these vessels.[1][2] Angiomas are a frequent occurrence as patients age, but they might be an indicator of systemic problems such as liver disease. They are not commonly associated with malignancy. appears as lacunas (A), purple (C) or combination between blue and red (D).

MalignantThis glossary term has not yet been described. non-pigmented oral lesions

  • Oral florid papillomatosis is a verrucous carcinoma which displays a whitish global aspect, sometimes network-like pattern.
  • The squamous cell carcinomaThis glossary term has not yet been described. of the lip shows many colors, reddish-purple, yellowish to brownish crust and white aspect.

Other non-pigmented oral lesions

Anatomical variant

  • Fox-Fordyce spots are small white-yellowish dots clustered.

Inflammatory and immune lesions

  • Mucosal lichen planusThis glossary term has not yet been described.: the dermoscopy shows the equivalent of the Wickham streakslines, radial (always at periphery) Reed nevus, melanoma, recurrent nevus on the mucosal surface.
  • Mucosal involvement in vulgaris pemphigus is non-specific, hard to be differentiated from squamous cell carcinoma.

Sexually transmitted diseases- Syphilis

  • Primary change as a extragenital localization: homogenous purple red if Hunterian, whitish structureless if atypical.
  • Secondary mucosal plaques are red-whitish and humid.


Pigmented oral lesions

Displays different aspects depending on the pigmentation: constitutive and acquired, benignant and malignant.

Benign pigmented oral lesions

Constitutive (natural) pigmentation

  • Shows a homogenous (structureless) aspect, dark brown, violaceous and a combination between brown and sometimes gray.

Melanotic macule

  • Shows even parallel pattern, with linear distribution of pigmentation, even structure less (light brown) or homogenous light brown 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..
Smoker melanosis
  • It is brown-black homogenous, sometimes with a honeycomb pattern, but nor having a pigmented network pattern.

Mucosal neviThis glossary term has not yet been described.

  • They have to be differentiate from mucosal macule and sometimes this is difficultThis glossary term has not yet been described.. Dermoscopically they display pigmented network (reticular patternA lesion with a reticular pattern has typical pigment network throughout the entire lesion.) and dotted-globular patternThis glossary term has not yet been described.. Few colors and the lack of structureless areas.

Pigmentations of the oral mucosa

  • They are common in IV, V, Vi skin types (4) and rare to Caucasians. Gingivae and buccal mucosae are the most common sites for oral pigmentations. A study (4) conducted on 1,275 patients did not find mucosal melanomaThis glossary term has not yet been described. and have split the pigmented pathologyThis glossary term has not yet been described. in oral area into: racial pigmentation, amalgam tattoo, focal melanotic macules, postinflammatory pigmentation, pigmentation due to medications, heavy metal deposits, and oral nevusThis glossary term has not yet been described..

Malignant pigmented oral lesions

Mucosal melanoma or any other malignancy

  • They must be excluded when dermoscopically the combination of blue, gray, or white color with structureless zones are visible. Even blue, gray, or white color alone could be a hint for any malignancy. Often the malignant lesions are asymmetric with a disorganized pattern.

Dermoscopy of genito-anal lesions

Non-pigmented genito-anal lesions

Benign non-pigmented genito-anal lesions

Angiomangiomas are benign tumors derived from cells of the vascular or lymphatic vessel walls (endothelium) or derived from cells of the tissues surrounding these vessels.[1][2] Angiomas are a frequent occurrence as patients age, but they might be an indicator of systemic problems such as liver disease. They are not commonly associated with malignancy.

  • Violaceous, red or combination red-blue, red-black, homogenous pattern.

Fox-Fordyce spots

  • It has the same aspect as in oral localization.

Inflammatory lesions

  • It has the same dermoscopic pattern as in the normal skin: e.g. lichen planus, lichenus sclerosus et atrophicans, psoriasisThis glossary term has not yet been described., vitiligo.

Sexually transmitted diseases

  • e.g. primary syphilis, non pigmented genital wartsThis glossary term has not yet been described. (HPV infection), secondary syphilis.
  • In molluscum contagiosumThis glossary term has not yet been described., Seize and coworkers found (5) that at clinical examination and dermoscopy of 211 lesions, orifices were visualized in 50.2% and 96.7% of the lesions, and vesselsThis glossary term has not yet been described. in 6.2% and 89.1%, respectively. The vascular patterns found in the 188 lesions in which vessels were found at dermoscopy were the crown (72.3%), radial (54.3%) and dotted patterns (20.2%). Half of the 188 lesions had a combination of vascular patterns, with the flower pattern (a new vascular pattern) being found in 19.7% of cases. More orifices and vessels were identified at dermoscopy than at clinical examination, including cases with inflammation or perilesional eczema and small lesions. Dotted vesselstiny pinpoint vessels flat melanocytic lesions inflammatory diseases Bowen disease were associated with inflammation, excoriation and perilesional eczema.
  • The dermoscopy of non-pigmented warts in male population (6) shows a non-specific pattern, or a fingerlike pattern, a mosaic and oval with projections pattern. Different vessels are seen (glomerular, hairpin/dotted) in many cases, but not in all of them.

Malignant non-pigmented genito-anal lesions

Vulvar/penile dysplasia

  • Cerebriform patternIs a dermoscopy pattern that resembles the aspect of a brain. Commonly seen in seborrheic keratosis., lack of multicomponent patternThis glossary term has not yet been described. (7) and bowenoid papulosis.
  • Bowenoid papulosis (BP) corresponds to an in situThis glossary term has not yet been described. squamous cell carcinoma (SCC) located in the anogenital region. It is related to HPV and presents dermoscopically a linear arrangements of brown-grey dots or simply grey dots and dotted vesselstiny pinpoint vessels flat melanocytic lesions inflammatory diseases Bowen disease which are widespread (8).
  • The Queyrat erythroplasia, the genital verrucous carcinoma (Buschke-Lowenstein tumor) or the invasive genital squamous cell carcinoma display structureless areas, many colors and chaotic non-pigmented dermoscopic features.

Amelanotic melanomatype of skin cancer in which the cells do not make melanin

  • Even non-pigmented melanomas could be diagnosed dermoscopically (11): structureless and polymorphia of vessels are the hint herefor.

Genital metastases

  • They are non-specific, peculiar being shown as slate-blue if non-pigmented or reddish.

Pigmented genito-anal lesions

Benign pigmented genito-anal lesions

  • The differentiation between benignant lesions (vulvar/penile melanosis, vulvar/penile nevi), and malignant pigmented ones (e.g. mucosal melanoma, pigmented BowenThis glossary term has not yet been described.`s disease) is essential.
  • The benign melanosis of the mucosa presents organized pattern (parallel and also reticular or ring-like) (1,7,9).

Malignant pigmented genito-anal lesions

  • Mucosal melanoma or any other malignancy must be excluded when dermoscopically the combination of blue, gray, or white color with structureless zones are visible. Even blue, gray, or white color alone could be a hint for any malignancy. Often the malignant lesions are asymmetric with a disorganized pattern.
  • In the darker skin pigmentation (constitutive) homogenous brown-greyish aspect is present.

Differentiation of mucosal lesions

For non-experts in dermoscopy it is difficult to check for all these patterns in order to differentiate between benignant and malignant lesions in mucosal areas. Therefore, we propose a simplified rule on mucosal:

  • The combination of blue, gray, or white colours with structureless zones are the strongest indicators when differentiating between benign and malignant mucosal lesions in dermoscopy, mainly in older patients.

Easy to be followed, this rule is based on previous research (9) and can be explained by some morphological origins and behaviour of the cells:

  • Normal melanocytes are involved in mucosal melanosis and in constitutive hyperpigmentation, as well as keratinocytes.
  • Unlike keratinocytes, in melanoma the melanocytes are retained into the epidermis, even if the get mutation and do not show apoptosis.
  • The origin of malignant melanocytes in mucosal is uncertain and they invade mucosal and sub mucosal, without dendritic projections.
  • The origin of nevocytes is neural crests and are distributed into the dermis or to the dermo-epidermial junction.


Pattern Aspect Signal for
Parallel pattern The pigmentation is linear distributed (wispy linear streaks) Vulvar melanosis, in focal areas of mucosal melanoma, pigmented warts
Structureless (homogenous) pattern Diffuse light to dark brown, black, grey-blue pigmented or white areas devoid of any visible structures. In white structures polymorhia of vessels could be visible Highly suggestive for melanoma, mainly in elderly people
Reticular patternA lesion with a reticular pattern has typical pigment network throughout the entire lesion. Honeycomb pattern of pigmented network
Dotted globular pattern Dots and globules MelanocyticThis glossary term has not yet been described. lesions

Bowenoid papulosis

Ring-like pattern Do not form a complete circle (“fish scale like structures”) Melanosis


References
  1. Blum A, Simionescu O. Mucosal Lesions. In: Marghoob AA, Malvehy J, Braun RP, editors. An Atlas of Dermoscopy, [Internet]. Second Edi. CRC Press Taylor and Francis Group; 2012. p. 301–9. Available from: https://www.crcpress.com/An-Atlas-of-Dermoscopy-Second-Edition/Marghoob-Malvehy-Braun/p/book/9780415458955
  2. Laguna C, Pitarch G, Roche E, Fortea JM. [Atypical pigmented penile macules]. Actas Dermosifiliogr [Internet]. 2006 Sep [cited 2017 Aug 7];97(7):470–2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16978549
  3. de Giorgi V, Massi D, Brunasso G, Salvini C, Mastrolorenzo A, Zuccati G, et al. Eruptive multiple blue nevi of the penis: a clinical dermoscopic pathologic case study. J Cutan Pathol [Internet]. 2004 Feb [cited 2017 Aug 7];31(2):185–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14690465
  4. Hassona Y, Sawair F, Al-karadsheh O, Scully C. Prevalence and clinical features of pigmented oral lesions. Int J Dermatol [Internet]. 2016 Sep [cited 2017 Aug 7];55(9):1005–13. Available from: http://doi.wiley.com/10.1111/ijd.13133
  5. Ianhez M, Cestari S da CP, Enokihara MY, Seize MB de PM. Dermoscopic patterns of molluscum contagiosum: a study of 211 lesions confirmed by histopathologyThis glossary term has not yet been described.. An Bras Dermatol [Internet]. [cited 2017 Aug 7];86(1):74–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21437525
  6. Dong H, Shu D, Campbell TM, Frühauf J, Soyer HP, Soyer P, et al. DermatoscopyThis glossary term has not yet been described. of genital warts. J Am Acad Dermatol [Internet]. 2011 May [cited 2017 Aug 7];64(5):859–64. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0190962210003828
  7. Ronger-Savle S, Julien V, Duru G, Raudrant D, Dalle S, Thomas L. Features of pigmented vulval lesions on dermoscopy. Br J Dermatol [Internet]. 2011 Jan [cited 2017 Aug 7];164(1):54–61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20846309
  8. Marcucci C, Sabban EC, Friedman P, Peralta R, Calb I, Cabo H. Dermoscopic findings in bowenoid papulosis: report of two cases. Dermatol Pract Concept [Internet]. 2014 Oct 31 [cited 2017 Aug 7];4(4):61–3. Available from: http://www.derm101.com/dpc/october-2014-volume-4-no.4/dermoscopic-findings-in-bowenoid-papulosis-report-of-two-cases/
  9. Blum A, Simionescu O, Argenziano G, Braun R, Cabo H, Eichhorn A, et al. Dermoscopy of Pigmented Lesions of the Mucosa and the Mucocutaneous Junction. Arch Dermatol [Internet]. 2011 Oct 1 [cited 2017 May 25];147(10):1181. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21680757
  10. Tanioka M, Nakagawa Y, Maruta N, Nakanishi G. Pigmented wart due to human papilloma virus type 60 showing parallel ridge patternVolar pigmentation forming lines, parallel, diffuse and irregular, along the ridges or cristae superficiales (raised portion of the dermatoglyphics) in dermoscopy. doi.org [Internet]. John Libbey Eurotext; [cited 2017 Aug 7];19(6):643–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19709979
  11. Blum A, Beck-Zoul U, Held L, Haase S. Dermoscopic appearance of an amelanotic mucosal melanoma. Dermatol Pract Concept. 2016 Oct 31;6(4):23-25. eCollection 2016 Oct. PMID: 27867742