Palms and Soles
- 1 Dermoscopy of acral tumours
- 2 Pigmented lesions of volar skin
- 3 Non-pigmented tumours
- 4 The rule of the BRAAFF in Dermoscopy of acral melanoma
- 5 Management of melanocytic lesions in acral sites (volar skin)
- 6 Dermoscopy of subcorneal hematoma
- 7 Dermoscopy in non-tumor skin diseases
In multiple studies, dermoscopyDermoscopy is a non invasive diagnostic method. has led to a significant improvement in diagnostic accuracy of skin tumors in acralAcral melanoma is a type of skin cancer that occurs on fingers, palms, soles, and nail beds. sites. It can be also utilized to examine other skin disease in this location such as pyogenic granulomaThis glossary term has not yet been described., viral wartsThis glossary term has not yet been described. or tinea nigraThis glossary term has not yet been described. or infestations such as tungiasisThis glossary term has not yet been described.. In this chapter we will describe the dermoscopic aspects in acral skin both volar and non-volar sites. Ungueal dermoscopy will be described in a separate chapter of dermoscopediaDermoscopedia is the name of this website and is providing state of knowledge information concerning dermoscopy - a non invasive diagnostic method..
Dermoscopic specific features of skin tumours in volar skin are driven by particular anatomic characteristics of the skin in this situation. In the case of non-volar skin similar dermoscopic patterns are seen in other skin sites such as extremities. Because of this we will describe in this chapter the Dermoscopy of pigmented and non-pigmentedThis glossary term has not yet been described. tumours of volar skin in palmsThis glossary term has not yet been described. and solesThis glossary term has not yet been described..
Diverse dermoscopic patterns in the palmar and plantar regions have recently been defined to distinguish between benignis any condition that is harmless in the long run neoplasms and melanomaThis glossary term has not yet been described.. The dermoscopic patterns reported in melanocyticThis glossary term has not yet been described. neviThis glossary term has not yet been described. of these regions are the parallel furrow patternVolar pigmentation forming solid or dotted lines, parallel, thin, on the furrows (sulci superficiales or invaginations in dermatoglyphics). The lines are occasionally doubled, each line is beside the furrows., lattice-like patternVolar pigmentation forming thin lines, parallel on the furrow or sulci superficialis (invaginations in dermatoglyphics) and crossing perpendicular on the ridges and fibrillar or filamentous pattern. In addition to these some nevi may exhibit patterns previously described in non-volar skin such as globular patternThis glossary term has not yet been described., homogenous patternstructureless any color and reticular patternA lesion with a reticular pattern has typical pigment network throughout the entire lesion.. In areas with the transition of volar to non-volar skin in the Wallace line the lesions may exhibit a combination of one the typical volar patterns and non-volar pattern. One additional pattern with the name of globuleThis glossary term has not yet been described.-strike pattern has been described in small lesions in dark skin typeThis glossary term has not yet been described. population. In contrast to acral nevi melanoma exhibits different dermoscopic features because of the invasion of the skin structures in this location.
The main specific dermoscopic patterns of acral lentiginous melanoma are the parallel-ridgeThis glossary term has not yet been described. pattern and diffuse multicomponent pigmentation pattern. When acral lentiginous melanoma progresses a combination of colours and structures appears in a multicomponent patternThis glossary term has not yet been described..
The most specific dermoscopic finding in early acral malignantThis glossary term has not yet been described. melanoma is the presence of parallel-ridge pattern that is associated to melanoma in situThis glossary term has not yet been described.. This is a distinct dermoscopic pattern that consists of a tan to dark brown pigmentation of the ridges of the skin markings, normally detected in the macular portions of melanomas in acral localizations.
In a collaborative retrospective study of the International Dermoscopy Society 167 acral lesions (66 melanomas) were evaluated for 13 dermoscopic patterns by 26 physicians. Parallel furrow patternVolar pigmentation forming solid or dotted lines, parallel, thin, on the furrows (sulci superficiales or invaginations in dermatoglyphics). The lines are occasionally doubled, each line is beside the furrows., bizarre pattern, and diffuse pigmentation with variable shades of brown had the highest prevalence. The agreement for lesion patterns between physicians was variable. Agreement was dependent on the level of diagnostic difficulty. In a nimber of acral lentiginous melanomas áreas with dermoscopic benign patterns were observed in combination with malignant patterns.
All these patterns are found in different ethnic groups and skin types including Caucasian population, Asian population and African population.Schematics of the dermoscopy patterns in benign and malignant lesions. Parallel black lines represent the furrows of the volar skin markings and small white dots the eccrine duct openings.
- Parallel furrow pattern: pigmentation following the furrows;
- Lattice-like patternVolar pigmentation forming thin lines, parallel on the furrow or sulci superficialis (invaginations in dermatoglyphics) and crossing perpendicular on the ridges: pigmentation following the furrows plus linear bands of pigment crossing from one to the next like rungs of a ladder;
- Fibrillar/filamentous pattern: parallel fine streakslines radial (always at periphery) streaks Reed nevus melanoma recurrent nevus crossing the dermoglyphics in a tangential direction;
- Globular patternThis glossary term has not yet been described.: globules not associated with a parallel pattern;
- Homogeneous patternA pattern lacking any definable pigment structures, structureless pattern: light brown homogeneous pigmentation with an amorphous appearance;
- AcralAcral melanoma is a type of skin cancer that occurs on fingers, palms, soles, and nail beds. reticular pattern: well-defined pigment network not associated with the skin markings.
- Parallel ridge patternVolar pigmentation forming lines, parallel, diffuse and irregular, along the ridges or cristae superficiales (raised portion of the dermatoglyphics): linear pigmentation of the ridges;
- Diffuse multicomponent pigmentation: pigmented blotches of various shades of brown observed in some portions of the lesion;
- Multi-component pattern: abrupt edge, diffuse pigmentation, peripheral irregular globulesGlobules with variability in color, size, shape or spacing and distributed in an asymmetric fashion and 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)., multiple colors, atypical streaks in combination with localized areas exhibiting benign patterns (fibrillar, parallel furrow or lattice-like).
- When pigmentation cannot be classified into the following mentioned groups and lack any specific features of malignancy is considered a “non-typical pattern”.
A diversity of benign and malignant tumours may appear in volar skin. Amelanotic or hypopigmented acral melanoma that may account up to 34% in some series, has to be distinguished by the presence of vesselsThis glossary term has not yet been described. (polymorphic vessels, dotted vesselstiny pinpoint vessels flat melanocytic lesions inflammatory diseases Bowen disease, linear irregularlinear vessels with multiple bends vessels milky red structures and hairpin vessels ), white shiny streaks (chystaline structures), ulceration and in some cases remnants of brown pigmentation.
The rule of the BRAAFF in Dermoscopy of acral melanoma
In a study of Lallas and coworkers of a total of 603 lesions (472 naevi and 131 AMs) a scoring system (named BRAAFF) composed of six variables was associated with optimal area under the curve and sensitivity for the 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 AM. This method includes positive and negative predictors (furrow pattern and fibrillar patternLinear pigmented filamentous lines of similar length with one end at the furrows and oriented at a certain angle to the furrows and crossing the ridges).
BRAAFF score (Variables associated to risk of melanoma)
A total score of ≥ 1 is needed for a diagnosis of melanoma
- Irregular blotchMore than one blotch or a blotch that is located off center (+1)
- RidgeThis glossary term has not yet been described. pattern (+3)
- Asymmetry of structures (+1)
- Asymmetry of colours (+1)
- Furrow pattern (-1)
- Fibrillar pattern (-1)
ManagementThis glossary term has not yet been described. of melanocytic lesions in acral sites (volar skin)
Different authors have proposed algorithms for the managementThis glossary term has not yet been described. and clinical decision-making of melanocytic lesions in non-glabrous skin. These algorithms integrate clinical data such as the ageprocess of becoming older, size and evolutionis change in the heritable characteristics of biological populations over successive generations of the lesion (congenital vs acquired; stability vs enlargement) and the dermoscopic information (acral dermoscopic patterns). With the combination of this information a more accurate management of the lesions can be concluded with the recommendation of self examination and no intervention, follow-up or skin biopsy.
In the case of melanocytic lesions with malignant patterns (parallel ridge or irregular diffuse pigmentation) partial biopsies may be insufficient to confirm a malignant lesion in early stages by histopathologyThis glossary term has not yet been described. due the scarce cellularity and mild atypia of the melanocytic proliferation. In these cases where the pathologyThis glossary term has not yet been described. can conclude a melanocytic hyperplasia without sufficient features of malignancy, the clinical-pathological correlation is needed to guide the treatment of the patient with a complete excision of the lesion.
Benign lesions simulating malignant dermoscopic patterns
In some pigmented disorders not associated to skin neoplasms can produce a parallel ridge patternVolar pigmentation forming lines, parallel, diffuse and irregular, along the ridges or cristae superficiales (raised portion of the dermatoglyphics) that can be indistinguishable of the dermoscopic patterns in acral lentiginous melanoma. In these situations the clinical information of age, traumatism, treatments, exogenous chemical pigmentation with paraphenil diamina or genetic disorders are the diagnostic cluesEvidence, in an investigation. These conditions include: pigmentation of patients submitted to chemotherapy (i.e. 5 fluouracil, capacitabine), repetitive traumatism, Peutz-Jeghers syndrome or racial pigmentations in dark skin. Some of these disorders are described in this chapter.
Dermoscopy of subcorneal hematoma
Subcorneal hematoma may mimic a melanocytic lesion and dermoscopy is useful to confirm the differential diagnosis. The red-black hue is the most frequent 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. seen by dermoscopy (40% of the lesions) and a homogeneous patternA pattern lacking any definable pigment structures, structureless pattern of pigmentation is the most frequent dermoscopic structure (53.3%). Remarkably, in a study of these lesions 40% of them exhibited a parallel-ridge pattern that is usually found in early melanoma of palms and soles. In 46.7% of the lesions, red-black globules were additionally seen at the periphery as satellites disconnected from the lesion's body. Only two lesions showed either parallel-furrow or fibrillar pattern. A scratch testThis glossary term has not yet been described. performed in these lesions, may allow complete or partial removal of the pigmentation. Similarly in lesions caused by repeated traumatism due to play station manipulation has been described with a brownish pigmentation simulating a parallel ridge pattern of melanoma. In these situation the clinical history, location on the fingers symmetrically distributed and young age that is not described in acral lentiginous melanoma were the main clues for the differential diagnosis.
Dermoscopy in non-tumor skin diseases
appear as a verrucous, yellowish tumour with structureless areahomogenous pattern various diagnoses exhibiting a variable number of irregularly distributed red to brown to black dots or linear streaks (hemorrhages), which are thought to be caused by the chronically high vascular pressure at plantar sites black dots typically seen in these viral infection. These hemorrhages are a helpful criterion to distinguish plantar warts from callus due to chronic friction, which lacks blood spots, but instead typically reveals central reddish to bluish structureless pigmentation to treatments or the differential in equivocal situations. The dermatoscopeThis 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. has been proposed to be more sensitive for the evaluation of response to treatment when the haemorrhagic dots disappear,
This infection may produce a clinical macular brownish to grey patch with thin bundles of spicules in a parallel ridge distribution that allows the differentiation form a melanocytic lesion
Tungasiasis has its own chapter in the dermoscopipedia. It has been described at 20-fold magnification as a typical brown-pigmented ring with a central pore that corresponds to the pigmented chitin surrounding the posterior opening of the flea exoskeleton. However tungiasis may exhibit variable dermoscopic features including blue-to-black area, structures in a radial pattern. It might be speculated that these structures correspond to eggs, but it might also be hematin in the gastrointestinal tract of the parasite.
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