Melanocytic lesions with peripheral globules: results of an observational prospective study in 154 high-risk melanoma patients under digital dermoscopy follow-up evaluated with reflectance confocal microscopy.

BACKGROUND: The management of melanocytic lesions with peripheral globules (MLPGs) is usually age-dependent and can be challenging in high-risk melanoma patients. OBJECTIVES: To evaluate clinical, dermoscopic and reflectance confocal microscopy (RCM) features of MLPG in patients under digital dermoscopic surveillance. To know whether dermoscopic or RCM findings correlate with histologic diagnosis and the accuracy of the dermoscopy-RCM compared with histopathology. METHODS: During 24 months, we prospectively enrolled MLPG in patients under digital dermoscopy follow-up. All were evaluated by dermoscopy and RCM and excised for histologic examination. RESULTS: We enrolled 154 patients, mean age 42.45 years (18.78-73.19). Three melanomas and 19 dysplastic naevi (DNs) were diagnosed. There were no significant differences in the age of the patients (P = 0.662). MLPGs with diameter of 6 mm or more and asymmetry in two axes were associated with melanoma (P = 0.01, P = 0.003). Patients with more than one MLPG were less likely to have melanoma. Blue-grey and red colours were more frequent in melanoma (P = 0.013 and P = 0.000). Different sizes and shapes of PG were associated with DN and melanoma (P = 0.000 and P = 0.001). In a new lesion, PG in <25% of the circumference was related to malignancy (P = 0.010). RCM signs of malignancy were related to melanoma: pagetoid cells (P = 0.000), non-edged papillae (P = 0.001), atypical junctional thickenings (P = 0.000) and atypical cells at the dermal-epidermal junction (P = 0.000). Dense irregular nests were associated to melanoma (P = 0.019). Dermoscopy and confocal evaluation were able to diagnose 100% of melanomas and 84.21% of DNs. The kappa coefficient between dermoscopy-RCM vs. histology was 0.76. CONCLUSIONS: We recommend to excise a MLPG when it presents asymmetry in two axes, 6 or more mm, new lesion with PG in less than the 25% of the circumference, irregular size and shape PGs and irregular dense nests on RCM, regardless of the patient's age.

Reflectance Confocal Microscopy: A Promising Tool to Identify Malignancy in Melanocytic Lesions Exhibiting a Dermoscopic Island. / Microscopia confocal de reflectancia: una herramienta útil para diagnosticar malignidad en lesiones melanocíticas que presenten el signo de la isla.

The dermoscopic island is described as a well-defined area in a melanocytic lesion, with a different dermoscopic pattern from the rest of the lesion. It is predictive of melanoma, particularly when the pattern of the island is atypical. We present the reflectance confocal microscopy (RCM) findings in 3 lesions with dermoscopic islands: nevus-associated melanoma, melanocytic nevus, and in situ melanoma. The nevus-associated melanoma and in situ melanoma presented cellular atypia (atypical cells in isolation or forming nests) and architectural distortion on RCM. The nevus presented a dermoscopic island with a typical globular pattern with dense nests and no atypia on RCM. Dermoscopic island is mainly associated with in situ and nevus-associated melanomas. RCM offers good cellular resolution to the depth of the reticular dermis and is useful for diagnosing of melanomas presenting a dermoscopic island.

Pustular generalized perforating granuloma annulare.

We report a 84-year-old man with a 13-year history of recurrent generalized asymptomatic pustular lesions. Histology revealed areas of necrobiosis surrounded by palisading granulomas and transepidermal and follicular elimination of the necrobiotic material. A dense infiltrate of neutrophils was also found. Although 26% of patients with generalized perforating granuloma annulare have some yellow pustule-like papules, these correspond histologically to the yellow viscous necrobiotic material extruding through the epidermis and not to a real neutrophilic infiltrate. This is the first case report of perforating granuloma annulare with recurrent generalized pustular lesions with a dense infiltrate of neutrophils.

[Acromelanosis]. / Acromelanosis.

Acromelanosis is an independent disease entity, characterized by increased skin pigmentation, usually located on the acral areas of the fingers and toes. It is mostly seen in newborns or during the first years of life. Only a few cases of this entity have previously been described in the medical literature. In some of these cases, the cutaneous lesions spread to affect large parts of the skin surface. A possible association with other benign and malignant diseases has been proposed. Differential diagnosis must be made with a wide variety of systemic and dermatologic conditions, especially dermatoses with acral distribution of macular hyperpigmentation, including acropigmentation. In this article, we report a new case of acromelanosis in a 5-week-old girl showing two peculiar clinical features: associated melanosis of the genital mucosa and stabilization of the lesions after an initial phase of progression and proximal spread. In addition, the most important features of this rare cutaneous disease are discussed.