|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 253-254
Acral lentiginous melanoma: Dermoscopic perspective in skin of color
Balachandra S Ankad1, SV Smitha1, Balakrishna P Nikam2
1 Departments of Dermatology, S Nijalingappa Medical College, Bagalkot, Karnataka, India
2 Krishna Institute of Medical Sciences, (Deemed to be University), Karad, Maharashtra, India
|Date of Submission||01-Apr-2020|
|Date of Decision||19-Aug-2020|
|Date of Acceptance||06-Oct-2020|
|Date of Web Publication||26-Aug-2021|
Balachandra S Ankad
Department of Dermatology, S. Nijalingappa Medical College, Navanagar, Bagalkot - 587 102, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ankad BS, Smitha S V, Nikam BP. Acral lentiginous melanoma: Dermoscopic perspective in skin of color. Clin Dermatol Rev 2021;5:253-4
Dermoscopy is an in vivo noninvasive technique being utilized for the assessment and diagnosis of a plethora of skin conditions. In the past, it was developed to rule out melanoma from other pigmented skin lesions. In the last decade, its applications are extended to inflammatory diseases. Here, we describe the dermoscopic patterns in acral lentiginous melanoma (ALM) with metastasis in Fitzpatrick skin Type IV with an account of dermoscopic context in skin of color.
A 70-year-old female came to the casualty with breathlessness and backache for 5 days. She gave a history of a pigmented lesion on the left sole for 6 years. Cutaneous examination revealed an ill-defined, hyperpigmented, 4 cm × 4 cm plaque with irregular borders; pigmentation; and ulceration with a rough surface over the upper part of the left sole [Figure 1]. Left inguinal lymph nodes were swollen and ulcerated. Chest X-ray showed bilateral “cannonball” appearance. Dermoscopic examination was done with DermLite 4 with smartphone attachment. It demonstrated asymmetry in the color, blue-white veil, regression areas, and multiple micro-ulcerations. Parallel ridge pattern with abrupt margins, asymmetry in the structures, irregular blotch, and adherent fabric fibers were noted [Figure 2]a and[Figure 2]b. Histopathology showed irregular epidermal acanthosis with lentiginous nesting of atypical melanocytes at dermoepidermal junction, and heavily melanized melanocytes with pleomorphic nuclei were seen [Figure 3]a and [Figure 3]b. Based on the clinical, dermoscopic, and histopathological features, a diagnosis of ALM with metastasis was made.
|Figure 2: Dermoscopy of acral lentiginous melanoma (a and b) reveals ridges (yellow stars) and furrows (yellow arrows) with parallel ridge pattern (yellow circle). Different shades of brown and black (red arrows) color are well appreciated with abrupt margins (blue arrows). Note the blue-white veil (red star) and adherent fabric fibers (black arrows) (b)|
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|Figure 3: Histopathology of acral lentiginous melanoma shows irregular epidermal acanthosis with lentiginous nesting of atypical melanocytes at dermo-epidermal junction. Heavily melanized melanocytes with pleomorphic nuclei and few pagetoid tumor cells in the spinous layer of epidermis are seen ([a] ×100). Spindle shaped atypical melanocytes in the papillary dermis is seen ([b], ×400) (H and E)|
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Dermoscopy is an excellent tool in diagnosing pigmentary disorders, which helps in differentiating melanomas from benign lesions such as acral nevus and seborrheic keratosis and cancerous diseases such as basal cell carcinoma and pigmented Bowen's disease. Acral skin is anatomically and histologically unique and characterized by a thick, compact cornified layer and presence of dermatoglyphics, pigment deposition along ridges, and furrows, creating particular dermoscopic patterns exclusive to these sites.
In a recent report of dermoscopy of ALM in skin color, “black pepper grain” pattern in addition to parallel ridge pattern, irregular blotches, pseudopods, and bluish-white veil was described. “Black pepper grain” pattern is nothing but the presence of intermittent black dots and streaks in a white structureless area. In this study, dermoscopic patterns were in the same line except for the “black pepper grain” pattern. However, adherent fabric fiber sign was not mentioned in the previous study. Adherent fabric fiber sign is a special clue in dermoscopy. It indicates that the given lesion is ulcerated and it would assist in the recognition of micro-ulceration. Identification of micro-ulceration in dermoscopy is highly suggestive of malignant change and invasiveness of a tumor. A study by the International Dermoscopic Society declared that parallel furrow pattern, bizarre pattern, and diffuse pigmentation with variable shades of brown are prevalent dermoscopic features in acral melanoma. Similar findings are seen in a previous report and in the present study. However, the intensity of pigmentation is greater in the present study.
Pigmentation in the furrow speaks of benign nevus, whereas pigmentation in the ridge is highly suggestive of melanoma. As the amount of melanin in Fitzpatrick skin Types IV, V, and VI is more as compared to that of I, II, and III types, intense pigmented globular structures are observed in the pigmented lesions in the former skin types. These highly pigmented globules may articulate into structureless areas and are the expected dermoscopic features in benign melanocytic nevi also. Furthermore, pigment globules may extend from furrows to ridges in a given lesion. Hence, during dermoscopic examination in skin color, it is advised to scope the entire lesion and contemplate the dermoscopic features in alliance with all the features. Furthermore, dermoscopic patterns should be analyzed based on the skin type. Otherwise, benign nevus with profound pigment would appear like melanoma in dermoscopy. Dermoscopic differences are depicted in [Table 1].
|Table 1: Dermoscopic differences between acral melanocytic nevus and acral lentiginous melanoma|
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To conclude, dermoscopy benefits in the diagnosis ALM by demonstrating characteristic patterns and also facilitates in the selection of site of biopsy for the greater yield of histopathological outcome. However, dermoscopy should not practice in isolation, but there should be a clinico-dermoscopic-histopathologic correlation for accurate diagnosis of given lesion in general and grading of a cancerous lesion in particular.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]