I have accepted with great pleasure to present this work
by my friend and colleague, Giovanni Di Lorenzo.
The richness and high quality of the images justify the effort,
love and competence given by the author in accomplishing
I have personally participated in the construction of this experience
over the years, supplying support in histopathology.
Over time the two activities have been refined and where
possible diagnostic evaluations have coincided more and
I thank him for having invited me to write these lines since it
gives me the chance to reaffirm that despite all, morphology
maintains its role as the backbone of medical knowledge and
that this is what we continue to consult in order to validate the
results of “progress”.
However, let us not forget that “the eye sees what the mind
knows” (Wolfgang Goethe).
Prof. Marcello Filotico
Specialist in Anatomy and Pathologic Histology
Former Chief at the V. Fazzi Hospital, Lecce
The radical excision of a skin growth considered atypical,
according to codified criteria, or else the conservative surgical
removal of growths believed to be benign, especially in
regions with high esthetic impact, has always meant an unavoidable
and consolidated procedure for the surgeon.
With this goal in mind, to improve diagnostic accuracy and
to allow correct surgical management, the author feels the
need to correlate the clinical appearance of a growth with
“sub-macroscopic” images using a noninvasive diagnostic
technique able to reveal criteria and morphological patterns
that are not visible to the naked eye.
Thus many years ago this educational journey and clinical
professional experience came about (necessary for the plastic
surgeon, who also deals with these pathologies), represented
by the knowledge and use of dermoscopy, a simple
routine technique for managing the diagnostics of diseases
of the skin and others, and which today still continues to hold
new attainments but also surprises.
Ten years later the author has collected in this treatise on
clinical dermoscopy a prevalently illustrative series of skin neoplasms
with essential dermoscopic references, specific for
each chapter, even if there are some cases that are difficult
from a diagnostic-clinical and histopathological point of view.
Dr. Giovanni Di Lorenzo
The Great Mimics of Melanoma: Reed Nevus 15
The great mimics of melanoma: Spitz Nevus 45
Severe Dysplasia 71
Lentigo Maligna 85
Melanoma in situ and with superficial diffusion 91
Melanoma with Breslow ≤ 1 mm 111
Melanoma with Breslow > 1 mm 137
Utility and limitations of dermoscopy in
preoperative differential diagnostics 155
GENERAL Bibliography 175
ASPECTS OF THE DERMATO-ONCOLOGICAL DIAGNOSTIC PATHWAY
DERMOSCOPY AND EPILUMINESCENCE
In the face of an increase in skin tumors and in particular of melanomas, today we
are witnessing a continuous flourishing of noninvasive diagnostic methods aimed at
making diagnosis as precocious and reliable as possible.
Pigmented lesions of the skin lend themselves well to examination with these methods
which include dermoscopy, certainly the most interesting one, for its practicality,
immediateness and relative simplicity of execution as well as from a scientific point
of view as it allows examination of the disposition within the lesion, specifying whether
it is melanocytic or not.
Any pigmented lesion analyzed with this procedure will reveal morphological characteristics
that are not noticeable with the naked eye, for which it is correct to state
that dermoscopy consists of a “bridge” between clinical practice and histology.
We can use a simple dermoscope, with x10 magnification with illumination, still
considered the standard instrument for performing dermoscopy, or a videodermoscope,
which is a high-resolution color video camera that visualizes the image on a
computer monitor and can be archived according to the suggested objectives.
With this method lesions can be observed live and with a greater magnification
compared to a simple dermoscopy, up to X 30-50-80, giving a more detailed analysis
of the lesion.
The use of epiluminescence for analyzing skin dates back to the XVII century when
Kolhause observed the blood vessels of the nail matrix, but it is only in 1916 that Carl
Zeiss made the first dermoscope and only in 1981 was differentiation of benign and
malignant melanocyte lesions introduced, based on the different patterns in their
– epiluminescence microscopy,
– reflected light microscopy,
– skin surface microscopy.
Basic criteria of dermoscopy
Close examination of a pigmented lesion proceeds by degree:
1. study of the global aspects of the lesion, overall view
2. study of the specific local aspects, detailed view.
This refers to the overall structure of the lesion that can have different patterns:
This is the most frequent global aspect of melanocytic lesions and is characterized by
the presence in the growth of a set of thinner or thicker pigmented lines, generally
brown, which crisscross each other to form a pigment network. This pattern is characteristic
of the acquired melanocytic nevus and the lentigo
This is characterized by the presence inside the lesion of numerous rounded or oval
pigment structures varying from brown to gray-black in color. It is frequently found in
the compound or dermal melanocytic nevus. The cobblestone pattern is similar to
the globular one with the difference that the globules are larger.
Characterized by the absence of the pigment network and by the presence of a
diffused and rather homogeneous pigmentation, with color varying from brown to
blue-gray and black. This pattern is found in:
– blue nevus (bluish color),
– nodular melanoma (black color),
– hemangioma (reddish-bluish coloring).
Characterized by the presence of pigment streaks distributed radially to the border
of the lesion with a fingerlike or drumstick appearance. This is found basically in the
Reed-Spitz nevus and in melanoma.
Found on the palms and soles and characterized by the arrangement of the pigment
along the furrows and ridges. There are numerous morphological variations in relation
to the specific local aspects. The parallel furrow pattern and its variations are found in
benign melanocyte lesions. The parallel ridge pattern is typical of melanoma.
Characterized by the presence of three or more dermoscopic structures (pigment
network associated with an accumulation of globules with hyper-hypopigmented
zones). This is found essentially in melanoma and in pigmented basal cell epithelioma.
A round or oval structure, with regular outline and reddish-bluish in color (red lacunae)
in the absence of a pigment network. It is typical of hemangioma and angiokeratoma.
Generally found in non-pigmented growths and characterized by the absence of
the patterns described above. It is found in amelanotic melanoma.
After the first overall morphological approach careful observation of the local characteristics
that make up a certain type of pattern allows for a better definition of the
benign nature of the growth or else suspicion of a diagnosis of an atypical or malignant
In observing the pigmented lines that make up the network the pigment crisscrossing
must be examined for color, thickness and location. This lets us understand if we have
a typical crisscross (tight, equal meshing, with regular distribution in benign melanocyte
growths) or an atypical mesh (darker, thicker and with irregular distribution in
Dots and globules:
Are pigment structures of different sizes, either round or oval, varying in color (black,
brown, gray, blue, in relation to the epidermal-dermal location), with a regular distribution
in the center of benign melanocytic growths and an irregular arrangement at
the border in malignant growths.
Streaks and pseudopods:
Are linear pigmented structures, digitiform or bulbous, distributed radially and at the
border, with a regular arrangement in benign melanocytic growths and an irregular
and asymmetrical arrangement in malignant growths.
This term is used to describe a hyperpigmented area, from brown to black, extend often
within the entire lesion or else with a multifocal (blotches) or localized distribution.
In benign melanocytic growths these blotches of pigmentation are localized in the
center with even coloring and regular outlines while in malignant growths they often
have an asymmetrical localization at the border and vary in color.
Represents in a pigmented growth a particular local aspect characterized by a decrease
in or absence of pigment. These areas are usually located in the center with
coloring similar to the peri-lesion skin in benign growths while in malignant ones they
are found at the border and are generally lighter than the surrounding skin.
This term includes different dermoscopic aspects characterized by pigment regression.
Thus the whitish scar-like areas, an expression of dermal fibrosis, are frequently
observed in melanoma with surface development while the gray-blue veil or the
gray-blue areas, an expression of dermal fibrosis with hyperpigmented and melanophage
melanocytes, are found more often in melanoma. This also includes peppering,
a dermoscopic aspect characterized by numerous gray-blue dots in the regression
Frequently observed in melanoma, with the hue varying from dirty white to light blue,
it is made of hyperpigmented melanocytes in the dermis. It is also found in pigmented
basal cell epithelioma.
Dermoscopic observation of the vessels allow us to distinguish different morphological
– comma vessels in the dermal nevus,
– wreathlike vessels in sebaceous hyperplasia,
– arborizing vessels in basal cell epithelioma,
– hairpin vessels with a whitish ring in growths with a keratinocyte origin (epithelioma,
keratoacanthoma, actinic keratosis),
– hairpin vessels without the whitish ring and with an irregular shape in melanoma,
– dotted vessels in Spitz nevus, in actinic and seborrheic keratosis, but also in melanoma.
Dr. Valerio Cirfera
Specialist in Dermatology and Venereology
President CeSIDeL “Vanni Labrini”
Italian Center for Studies of Legal Dermatology