A case posted to the IDS forum by Keir Jeffrey
Age: 56 years, Sex: f, Location: lower leg, right
Clinical history: Patient not sure how long this has been there. Thinks it may have recently devloped the light pink area.
Diagnosis: What do you think?
Question: Are there any specific dermoscopic features that lead you to the conclusion you reach?
Answers (comments):
Burns John (12/7/2009 1:41:39 AM): MIS vs pigmented bowens. The hints of scale and the white halos around the vessels lean more towards the keratinizing spectrum. Thanks for the case and look forward to your comments/path.
Pyne John (12/7/2009 2:35:36 AM): Thanks Uncle Jeff. Abundant dot vessels, but not coil[no glomerular clusters]. Could be keratinocytic but more likely melanocytic.
This age, on the leg of a lady,.......you know what Iris will say.....and I will agree with her[Iris].
Zalaudek Iris (12/7/2009 10:38:12 AM): Well - Uncle John knows me very well :-))
1) Fair skin type obviously - this predicts that the criteria of a melanocytic tumor are usually less developed (although there is some network)
2) Dotted vessels in the center - usually glomerular vessels of Bowen are much more evident on the lower leg
3) Woman - leg and changes.
What is however speaking slightly against melanoma are the small erosions (often seen in BCC) and rarely seen in melanoma.
Bowen could be also an option ...
Thus, melanoma versus Bowen versus BCC - I rule out here dermatofibroma.
Rosendahl Cliff (12/7/2009 10:51:40 AM): This is a beauty Jeff! I think the clue is in the nature of the "lines reticular" in the SW. That pretty well rules out pigmented bowens and BCC and I reckon they are the type of "circles" seen in dermatofibroma. Of course you have to exclude melanoma. Did it pucker when you squeezed it Jeff?
Rosendahl Cliff (12/7/2009 10:52:39 AM): Bugger - Iris beat me to it!!
Keir Jeffrey (12/7/2009 12:14:12 PM): No puckering, Cliff!
Keir Jeffrey (12/7/2009 8:59:52 PM): The result: Pigmented Intraepidermal Carcinoma (Bowen's, pIEC). There was a very slight roughness to touch (I was remiss in not imparting that info), there are some non-network-related almost parallel (but slightly diverging) brown lines within the lesion to the lower left, which are sometimes seen with pIEC. But, the vessels weren't entirely consistent with pIEC and I was wondering at some sort of collision with a melanocytic lesion or MMis.
Burns John (12/7/2009 11:07:07 PM): Thanks for the informative case and follow up
Rosendahl Cliff (12/8/2009 4:54:00 AM): Great case Jeff. Yes I saw those radial lines but the reticlar lines put me off!
Cameron Alan (12/8/2009 8:51:34 AM): Nice one Jeff! Reticular lines are quite uncommon in pIEC... but in this case it is open to interpretation whether this area actually belongs to an adjacent solar lentigo. This skin with widespread chronic actinic damage is hard going.
Pyne John (12/9/2009 5:25:34 AM): Thanks Uncle Jeff, good case.
Zalaudek Iris (12/9/2009 6:46:53 AM): Great case Jeff, and one so often we are wrong - pink tumors - uuuahhh!!!
Bowen's disease (BD), or squamous cell carcinoma in situ, is a malignant epithelial tumor that rarely, in patients with dark skin types, may manifest as a pigmented Bowen's disease (pBD). PBD shares similar features with other pigmented lesions including pigmented basal cell carcinoma and melanoma. Diagnosis of pBD can be a challenge.
Specific dermoscopic findings of pBD include regular clusters of glomerular vessels and brown globules, especially in a linear arrangement. This specific pattern is not always present, and pBD should be considered in the differential diagnosis when a pigmented tumor displays absence or doubtful criteria of a melanocytic lesion associated with blue structureless areas, dotted vessels and scaly surface.
References:
1. Zalaudek, G. Argenziano, B. Leinweber et al., "Dermoscopy of Bowen's disease," British Journal of Dermatology, vol. 150, no. 6, pp. 1112–1116, 2004.
2. A. Cameron, C. Rosendahl, P. Tschandl, E. Riedl, and H.Kittler, "Dermatoscopy of pigmented Bowen's disease," Journal of the American Academy of Dermatology, vol. 62, no. 4, pp.597–604, 2010.