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Background: The recognition of amelanotic cutaneous melanoma metastases (ACMM) remains a diagnostic challenge., Objectives: To describe and analyze the clinical and dermoscopic characteristics of ACMM., Patients and Methods: Cases of ACMM were retrospectively selected from the image databases of three dermatology centers. The clinical and dermoscopic images were combined into one database for analysis., Results: Forty-seven ACMM were observed in 18 patients. All lesions were erythematous, symmetric, dome-shaped papules or nodules appearing an average of 17 months after the diagnosis of the primary melanoma. ACMM presented as clinical outliers or as nonspecific papules found by palpation of the skin. The predominant dermoscopic feature was the presence of vascular structures, including serpentine (45%), glomerular (30%), irregular hairpin (23%) and corkscres-like vessels (19%). A few lesions also revealed crystalline (or shiny white lines) when viewed using polarized dermoscopy., Conclusion: ACMM should be considered in the differential diagnosis of new or persistent skin-colored or pink papules in patients with a previous history of invasive melanoma, especially if the lesions reveal atypical vessels under dermoscopy. The presence of crystalline structures may be another clue for the detection of some ACMM., (© 2012 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Basal cell carcinomas (BCCs) can be diagnosed using different dermoscopic modalities., Objective: To evaluate dermoscopic features of BCCs using nonpolarized and polarized dermoscopy to highlight similarities and differences between dermoscopic modalities., Materials and Methods: Retrospective study of 149 BCCs under nonpolarized dermoscopy (NPD), polarized contact dermoscopy (PCD), and polarized noncontact dermoscopy (PNCD). Images were evaluated for a range of dermoscopic colors, structures, and vessels. Features were compared according to histopathologic subtype., Results: The most common dermoscopic structures in BCCs across all modalities included globules (50.3-51.0%), dots (49.7-50.3%), white structureless areas (63.1-74.5%), structureless gray-brown areas (24.2-24.8%), and ulcerations (28.2%). The most frequently observed vasculature included arborizing vessels (18.8-38.3%), short fine telangiectasias (SFTs) (73.8-82.6%), and vascular blush (41.6-83.2%). Structures with higher levels of agreement across modalities included pigmented structures and ulcerations. Lower levels of agreement existed between contact and noncontact modalities for certain vascular features. White shiny structures, which include shiny white lines (chrysalis and crystalline structures) (0-69.1%), shiny white areas (0-25.5%), and rosettes (0-11.4%), exhibited no agreement between NPD and polarized modalities., Conclusions: This study highlights differences in dermoscopic features of BCCs under three dermoscopic modalities. Shiny white lines (chrysalis and crystalline structures) and shiny white areas may be used as additional criteria to diagnose BCCs., (© 2011 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Diagnostic accuracy and preferred therapeutic strategies for actinic keratoses (AKs) and squamous cell carcinoma (SCC) have significant public health implications., Objective: To evaluate clinical-pathologic agreement on the diagnosis of AKs and early SCCs and to characterize the effect of diagnosis on therapeutic decisions., Methods & Materials: Nine dermatologists and two dermatopathologists reviewed an image-based dataset of AKs and early SCCs. Clinical-pathologic agreement, inter- and intraobserver reliability for clinical diagnosis, and frequencies of therapies according to pathologic diagnosis were assessed., Results: Clinical-pathologic (κ=0.10) agreement was poor, whereas interobserver (κ=0.24) and intraobserver (κ=0.28) agreements were fair. Participants were more likely to treat AKs with cryotherapy (64.2%) and to manage SCCs with surgery (72.8%). Therapeutic choice rarely changed after participants were shown histological photomicrographs. Participating clinicians treated most lesions histologically diagnosed as SCC in situ arising within AK using surgery, whereas pathologists selected cryotherapy or curettage and electrodesiccation for these lesions., Conclusion: We found poor clinical-pathologic agreement and reproducibility for clinically distinguishing between AK and early SCC even between skin cancer specialists from a single academic group practice. Nomenclature used in the pathologic diagnosis of AK and SCC affects clinicians' therapeutic decisions. The authors have indicated no significant interest with commercial supporters., (© 2010 by the American Society for Dermatologic Surgery, Inc.)

Background: Clear cell acanthoma (CCA) is a rare, benign neoplasm of unknown etiology, whose dermoscopic and histological features have been previously described. Usually, CCA can be diagnosed by clinical and dermoscopic examination. In some cases, diagnosis remains uncertain, and histological examination is needed. The aim of this paper was to describe the features of reflectance confocal microscopy (RCM) in diagnosing CCA, compare them with findings on dermoscopy and histology, and evaluate their possible usefulness in CCA evaluation., Patients and Methods: Five lesions diagnosed clinically as CCA were imaged using dermoscopy and RCM. All lesions were surgically excised to confirm the diagnosis and compare the morphological attributes under light microscopy with in vivo imaging., Results: RCM showed well-circumscribed lesions, often edged by a hyperkeratotic collarette with parakeratosis; inflammatory cells in the spinous layer; large keratinocytes; acanthosis with papillomatosis; epidermal disarray; and dilated capillaries forming glomeruloid shapes in the upper dermis., Conclusions: In this small study, RCM was able to identify most of the established diagnostic histological features of CCA. RCM appears to be a useful tool for in vivo diagnosis of CCA and may help avoid unnecessary biopsies.

Background: Studies have demonstrated differences in colors and dermoscopic structures observed with polarized dermoscopes (PDs) and nonpolarized dermoscopes (NPDs)., Objective: The objective was to evaluate whether diagnosis and diagnostic confidence changes when viewing dermoscopic images from NPDs and PDs., Methods: A total of 100 dermatologists participated in the study. Twenty-five pigmented lesions were shown in the study, consisting of 7 seborrheic keratoses (SK), 3 basal cell carcinomas, 2 atypical nevi, 5 malignant melanomas (MM), 3 dermatofibromas, 3 blue nevi, and 2 hemangiomas. Two images of each lesion (one NPD and one PD) were included. The McNemar test and paired t-test were used for the statistical analysis., Results: Ninety-one participants completed the study. Significant differences in the diagnoses were observed for the SK, atypical nevus, and MM images. Seventy-five percent and 59% of the final participants correctly diagnosed SK when presented with the NPD and PD images, respectively. For MM, 23 and 34% made the correct diagnoses with the NPD and PD images, respectively., Conclusions: Viewing lesions with NPD versus PD can affect the diagnosis and diagnostic confidence of physicians that are novices with dermoscopy. Further studies including physicians at different expertise levels and a larger sample of lesions are needed to further explore the differences.

The first step of the two-step algorithm of dermoscopy aims at differentiating melanocytic from nonmelanocytic pigmented lesions, using a stepwise evaluation for the presence of specific dermoscopic criteria. The purpose of this article is to heighten awareness of clinicians to nonmelanocytic lesions that defy the two-step algorithm, thus simulating melanocytic lesions dermoscopically. Seborrheic keratosis, solar lentigo, dermatofibroma, and supernumerary accessory nipple may present with network-like structures. Seborrheic keratosis, dermatofibroma, subcorneal hemorrhage, basal cell carcinoma (BCC), and cutaneous metastases of breast and other cancers may contain pigmented globules. Peripheral streaks can also be seen in seborrheic keratosis and BCC. Homogenous bluish pigmentation, simulating a blue nevus, can also be seen in benign vascular lesions, Kaposi sarcoma, radiation tattoo, and BCC. This overlap of features between melanocytic and nonmelanocytic lesions suggests that integration of all dermoscopic features in the lesion, rather than a stepwise evaluation, may facilitate reaching the correct diagnosis in select cases as outlined in this article.

Background: Melanocyte colonization of breast carcinoma cells may occur in those tumors that breach the epidermal-dermal interface. The resultant melanin deposition in tumor cells rarely leads to clinical pigmentation of the tumor. Typically, selective staining methods are required to detect the pigment., Observation: The authors describe a 60-year-old woman with a history of mammary carcinoma and an irregularly pigmented nodule with peripheral globules and a blue-white veil on dermoscopy, which was a clinical and dermoscopic mimic of malignant melanoma., Conclusions: Awareness of melanocyte colonization of non-melanocytic tumor cells and the dermoscopic-histologic correlations can aid in avoiding a potential pitfall, and emphasize the importance of such relationships, when using this tool.

Background: Confidence is an important factor in decision making and may influence patient care., Objectives: To evaluate whether short-training-based dermoscopy increases confidence in the diagnosis of skin lesions., Methods and Materials: After a 1-hour course on dermoscopy, 20 pairs of clinical and dermoscopic images of lesions were presented to 19 dermatology residents with little or no dermoscopy experience. After viewing the clinical image, they were asked to assess their confidence in the diagnosis in a seven-point scale, with 1 reflecting that the respondent was 100% confident that the lesion was benign, while number 7 reflected 100% confidence that it was malignant. The same technique was used for dermoscopic images., Results: Ten of the 20 pairs of evaluations showed a significant difference (p<.05). The largest differences were observed in lesions where clinical scores suggested that participants were uncertain about the diagnosis, but tended to decide that the lesion was benign after dermoscopy. Dermoscopy did not improve confidence in the evaluation of dysplastic lesions as well as lesions with obvious clinical diagnoses., Conclusions: Short-training-based dermoscopy improved confidence in the diagnosis of clinically challenging skin lesions, but the impact was not demonstrable for clinically obvious lesions and dysplastic nevi.

Background: The incidence of malignant melanoma (MM) in the United States (US) must be known to accurately evaluate the costs that MM imposes on the health care system and society in general. Furthermore, knowledge of the incidence is needed to determine the benefit of MM prevention programs., Objective: To obtain an estimate of the incidence of MM in the US., Methods: The data for this study were collected by means of a questionnaire that was sent to all members of the American Academy of Dermatology practicing in the US (N = 7412)., Results: Based on the mean number of MMs seen annually per dermatologist in each state and the number of dermatologists per state, the number of new in situ and invasive MMs in the US in 1992 was calculated to be 80,000. This translates to an incidence of 32 MMs per 100,000 persons., Conclusions: Our estimate of 80,000 new MMs diagnosed in 1992 in the US suggests that MM places much greater burdens on the US health care system and society than that based on current published estimates.