In this issue of the Archives, Menzies et al1 analyze a large number of hypopigmented lesions to determine the most useful dermoscopic features for detection of amelanotic and hypomelanotic melanoma (AHM). Dermoscopy, which uses magnification with a glass plate and fluid or with cross-polarized lighting, improves diagnostic accuracy for pigmented lesions.2 For clinical observation without dermoscopy, diagnostic sensitivity and specificity of AHM have been reported as 65% and 88%, respectively3; however, dermoscopy improves sensitivity and specificity to 89% and 96%, respectively.3 For truly amelanotic melanomas, diagnosis depends critically on vascular patterns, which are visible only by dermoscopy.
This hypomelanotic melanoma shows all “4V” dermoscopic features for hypomelanotic melanoma: predominantly central irregular linear, dotted, and hairpin vessels; bluish-white veil; variegated red to blue coloring including scarlike depigmentation, milky red or pink globules, and other shades of pink, blue, and gray; and irregular brown globules on the lesion verge. Image courtesy of Harold S. Rabinovitz, MD.
Flowchart for commonly misdiagnosed amelanotic or hypomelanotic melanomas. For descriptions of the “4V” rule and “BASAL” features, see Table 1 and Table 2, respectively. *Note that many amelanotic melanomas may be essentially featureless on dermoscopy. If not clearly benign, biopsy or excision should be considered. The risk of amelanotic or hypomelanotic melanoma is further increased for any of the following3,5,27,32,33: (1) any trace of pigment, (2) growth or change, (3) “ugly duckling” sign (nevus is not typical for that patient's nevi), (4) ulceration, (5) asymmetric lesion border, (6) personal or family history of melanoma or dysplastic nevus syndrome, and (7) Fitzpatrick type I or II or blistering sunburn history. †Some pink lesions (eg, scars) can be explained by the history and clinical examination. Note that patients, even those with dysplastic nevi, do not consider melanoma among the diagnostic possibilities for pink lesions. Any unexplained pink lesion, especially if solitary, should be considered for biopsy. ‡Concerning lesions on the foot, Soon et al27(p187) noted that “any nail deforming lesion or wart on the foot in an older person should be biopsied.” (In this series of 18 misdiagnosed melanomas of the foot, mostly amelanotic, 17 were located on either the plantar surface or a subungual location. Fifteen of the 18 patients were at least 60 years of age, and 4 had ulcers or drainage.27) §Biopsy of foot lesions and any hyperkeratotic lesions “should be excisional or a careful incisional biopsy rather than a shave biopsy because of acanthosis and hyperkeratosis in these lesions.”27(p187)
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