Dermoscopic Clues for Diagnosing Melanomas That Resemble Seborrheic Keratosis

Abstract

Importance: Melanomas that clinically mimic seborrheic keratosis (SK) can delay diagnosis and adequate treatment. However, little is known about the value of dermoscopy in recognizing these difficult-to-diagnose melanomas.

Objective: To describe the dermoscopic features of SK-like melanomas to understand their clinical morphology.

Design, setting, and participants: This observational retrospective study used 134 clinical and dermoscopic images of histopathologically proven melanomas in 134 patients treated in 9 skin cancer centers in Spain, France, Italy, and Austria. Without knowledge that the definite diagnosis for all the lesions was melanoma, 2 dermoscopy-trained observers evaluated the clinical descriptions and 48 dermoscopic features (including all melanocytic and nonmelanocytic criteria) of all 134 images and classified each dermoscopically as SK or not SK. The total dermoscopy score and the 7-point checklist score were assessed. Images of the lesions and patient data were collected from July 15, 2013, through July 31, 2014.

Main outcomes and measures: Frequencies of specific morphologic patterns of (clinically and dermoscopically) SK-like melanomas, patient demographics, and interobserver agreement of criteria were evaluated.

Results: Of the 134 cases collected from 72 men and 61 women, all of whom were white and who had a mean (SD) age of 55.6 (17.5) years, 110 (82.1%) revealed dermoscopic features suggestive of melanoma, including pigment network (74 [55.2%]), blue-white veil (72 [53.7%]), globules and dots (68 [50.7%]), pseudopods or streaks (47 [35.1%]), and blue-black sign (43 [32.3%]). The remaining 24 cases (17.9%) were considered likely SKs, even by dermoscopy. Overall, lesions showed a scaly and hyperkeratotic surface (45 [33.6%]), yellowish keratin (42 [31.3%]), comedo-like openings (41 [30.5%]), and milia-like cysts (30 [22.4%]). The entire sample achieved a mean (SD) total dermoscopy score of 4.7 (1.6) and a 7-point checklist score of 4.4 (2.3), while dermoscopically SK-like melanomas achieved a total dermoscopy score of only 4.2 (1.3) and a 7-point checklist score of 2.0 (1.9), both in the range of benignity. The most helpful criteria in correctly diagnosing SK-like melanomas were the presence of blue-white veil, pseudopods or streaks, and pigment network. Multivariate analysis found only the blue-black sign to be significantly associated with a correct diagnosis, while hyperkeratosis and fissures and ridges were independent risk markers of dermoscopically SK-like melanomas.

Conclusions and relevance: Seborrheic keratosis-like melanomas can be dermoscopically challenging, but the presence of the blue-black sign, pigment network, pseudopods or streaks, and/or blue-white veil, despite the presence of other SK features, allows the correct diagnosis of most of the difficult melanoma cases.

Figure 1.. Diagram of Seborrheic Keratosis (SK)–like Melanoma Detection by Different Dermoscopic Clues

A total of 134 clinically SK-like melanomas were evaluated; among them, 24 cases (17.9%) were considered possible SK (dermoscopically SK-like melanomas). Of these, 14 showed at least 1 recognizable criterion of a melanocytic lesion: pigment network, globules or dots, pseudopods, blue-white veil, and/or the blue-black sign.

Figure 2.. Four Seborrheic Keratosis (SK)–like Melanomas Belonging to the Group of 110 Lesions Easily Detected by Dermoscopy

Insets, Pigmented lesions with some degree of hyperkeratotic surface and sharp demarcation that clinically can simulate SKs. Larger images, Dermoscopy shows features suggestive of melanocytic lesions and therefore melanoma. A, Presence of pigment network at the periphery (arrowhead) with hyperkeratosis and blue-white veil in the center (circle). B, Brownish lesion with notable milia-like cysts (black oval) and yellowish keratin, pigment network (arrowhead), irregular globules and dots, and shiny white streaks (white circle). C, Blue-white veil and the blue-black sign in the center, in addition to atypical network (black arrowhead) and pseudopods at the periphery (blue arrowhead). D, Markedly hyperkeratotic tumor with verruciform surface and blue-white veil (white oval); the clue is at the periphery, with atypical network (arrowhead) and regression.

Figure 3.. Four Seborrheic Keratosis–like Melanomas Needing Careful Dermoscopic Evaluation to Be Correctly Diagnosed

A-D, Clinical photographs. In B and C, the rules are in millimeters. E-H, Dermoscopic images of the same lesions. Pigmented lesions with marked hyperkeratotic surface partially impeding the easy observation of the dermoscopic clues. The proper use of immersion liquid and enough light may help the evaluation (compare G, which did not have enough liquid, and H, which is a proper image that allows the detection of the pigment network [circle]). The presence of subtle pigment network (arrowheads in G and H) and globules (arrowhead in F) at the periphery of the lesions and the blue-black sign are the main key features. Regression features (box in E; circle in F) can be another clue to recommend excision.