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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 35  |  Issue : 2  |  Page : 75-81

Role of dermatoscope in diagnosing and differentiating different types of seborrheic keratoses


1 Department of Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Pathology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt

Date of Submission03-Nov-2015
Date of Acceptance27-Dec-2015
Date of Web Publication10-Mar-2016

Correspondence Address:
Nagla A Ahmed
MD, Department of Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-6530.178474

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  Abstract 

Background
Seborrheic keratosis (SK) is the most common benign skin tumour to be misdiagnosed clinically as melanoma. SK may grow rapidly, is dark coloured with black areas and is accompanied with itching. Thus, it is difficult to distinguish it from malignant melanoma on clinical basis.
Dermatoscope is a simple noninvasive tool useful for the early recognition of pigmented skin tumours, especially SK, melanoma and pigmented basal cell carcinoma, as it helps in differentiating each of them by specific criteria. In case a doubt about the diagnosis persists, biopsy is carried out for confirmation.
Aim of the work
The aim of the present study was to determine the role of dermatoscope in diagnosing and differentiating different types of SK, and its ability to detect suspicious lesions and confirm diagnosis by using histopathology.
Patients and methods
This study was carried out on 50 SK patients; out of them nine had suspicious lesions. All patients were subjected to dermatological, dermoscopic and histopathological examinations for suspicious lesions.
Results
In our study, the most common dermoscopic findings for different types of SK (stucco, dermatosis papulosa nigra, melanoacanthoma, flat type) were sharp demarcated border, comedo-like openings, milia-like cysts, moth-eaten borders and cribriform pattern. In addition, hairpin blood vessels and fat finger appeared in flat type SK.
In our study, the dermoscopic criteria of suspicious lesions (n = 9, 18%) was diagnostic by 22.2% to tumour, as it showed structureless area and blue gray clods (n = 1, 11.1%); structureless area, yellow clods and blue gray clods (n = 1, 11.1%); and sharp demarcated borders, comedo-like openings, moth-eaten borders, milia-like cysts and fissures and ridges (n = 7, 77.8%).
Overall, 22.2% of the biopsied cases were basal cell carcinoma and 77.8% were SK.
Conclusion
SK must be taken seriously with close follow-up by using dermoscopy to detect any malignant changes.

Keywords: Dermoscope, suspicious lesions, seborrhic keratosis


How to cite this article:
Abdel-Azim AA, Ahmed NA, Hamid GDA, Abdel Moaty NT. Role of dermatoscope in diagnosing and differentiating different types of seborrheic keratoses. Egypt J Dermatol Venerol 2015;35:75-81

How to cite this URL:
Abdel-Azim AA, Ahmed NA, Hamid GDA, Abdel Moaty NT. Role of dermatoscope in diagnosing and differentiating different types of seborrheic keratoses. Egypt J Dermatol Venerol [serial online] 2015 [cited 2020 May 28];35:75-81. Available from: http://www.ejdv.eg.net/text.asp?2015/35/2/75/178474


  Introduction Top


Seborrheic keratosis (SK) can sometimes clinically simulate a melanocytic lesion; therefore, a dermatoscope is needed to reach correct diagnosis [1]. Dermoscopy is a noninvasive in-vivo technique that allows a better visualization of structures in the epidermis, the dermal-epidermal junction and the superficial dermis. Therefore, dermoscopy improves clinical accuracy in diagnosing melanoma and other pigmented and nonpigmented skin lesions [2].

In addition, a study [3] claimed that dermoscopy increases the accuracy of diagnosing SK from 62 to 77% as the most common dermoscopic characteristics of SK (comedo-like openings and milia-like cysts) have a high prevalence, but using additional dermoscopic criteria, such as fissures, hairpin blood vessels, sharp demarcated and moth-eaten borders, improves the diagnostic accuracy.

In their study, Zaballos et al. [4] stated that histological confirmation is occasionally warranted, especially to rule out malignant processes, but isolated suspicious foci within larger lesions cannot be determined easily to direct pathological sectioning of such suspicious sites within a lesion.


  Patients and methods Top


Patients

This study was carried out on 50 SK patients; out of them nine cases had suspicious lesions. Participants were selected from the outpatient dermatology clinic at Al-Zahraa University Hospital and Al-Houd Al Marsoud hospital during the period from November 2013 to November 2014. All patients were subjected to dermatological, dermoscopic and histopathological examination for suspicious lesions.

Inclusion criteria

  1. Patients of both sexes were included in the study.
  2. Patients aged above 20 years were included in the study.


Methods

  1. A written informed consent was obtained from all patients.
  2. Patients were subjected to full history-taking.
  3. All patients filled a predesigned data sheet with emphasis on the following.


Personal history: This included name, age, residence and occupation. Special attention was paid to specific habits (e.g. sun exposure).

Past history: Systemic review of all patients for any internal systemic disease or chronic debilitating condition was carried out.

General examination: General examination was carried out for any systemic disease or chronic debilitating condition.

Dermatological examination: Detailed dermatological examination was carried out for each patient, with special emphasis on other skin lesions and skin tumours. Dermoscopic examination: All patients' SK were examined by using dermoscopy for the criteria of SK, other skin lesions and all suspicious lesions.

All the dermoscopic findings were photodocumented by using a digital camera.

  1. Biopsy: Biopsies (punch biopsy or excisional biopsy) of suspicious lesions were carried out for their histopathological examination.


Materials

A DermLite dermatoscope (DL1; GenTM, USA), with a full-size 15 mm lens optimized for iPhone and other smartphones and tablets, was used in the present study. Endowed with high-powered LED lighting, a high-performance rechargeable battery, and an all-aluminum design, smaller than the ring finger, it captures high-resolution images of excellent clarity and sharpness both in polarized and nonpolarized modes, with or without skin contact.

Statistical methods

The collected data were coded, tabulated and statistically analysed using IBM statistical package for social sciences, V. 22.0 software (2013; IBM Corp., Chicago, Illinois, USA).

Descriptive statistics were carried out for quantitative data, which were described as minimum and maximum of the range and as mean ± SD, whereas qualitative data were described as number and percentage.


  Results Top


A total of 50 patients were enrolled in this study; nine of them had suspicious lesions. The enrolled group in our study comprised 43 (86.0%) men and seven (14.0%) women, and their ages ranged from 22 to 82 years (mean ± SD = 64.4 ± 10.8 years) [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5] and [Figure 6].
Figure 1: A 60-year-old female patient with seborrheic keratosis on the face 5 years ago (a); dermoscopy showing cerebriform pattern, sharply demarcated border (red arrow) and moth-eaten border (black arrow) (b).

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Figure 2: A 75-year-old male patient with melanoacanthotic type seborrheic keratosis in the head 10 years ago (a); dermoscopy showing comedo-like opening (black arrow) and sharply demarcated border (white arrow) (b); histopathology of seborrheic keratosis showing hyperkeratosis (black arrow), proliferation of basaloid cells, horn cysts (yellow arrow) and proliferation of melaocytes (c). H&E, ×40.

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Figure 3: A 64-year-old male patient with seborrheic keratosis on the head 10 years ago (a); dermoscopy showing milia-like cyst (black arrow), comed-like opening (white arrow), fissures and ridges, sharp demarcated border, moth-eaten border (red arrow) and hairpin blood vessels (b).

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Figure 4: A 76-year-old male patient with seborrheic keratosis on the hand 10 years ago (a); dermoscopy showing cerebriform pattern, motheaten border (black arrow) and brown globular structures (red arrow) (b, c). Histopathology of SK showing hyperkeratosis (yellow arrow) and horn cyst (black arrow) (H&E, ×40) (d). Clinical image of SSC involving the head (e, h); dermoscopy of squamous cell carcinoma (SCC) (f). The lesion of the patient associated with SSC involving the whole head of the patient. The diagnosis was confirmed by carrying out a biopsy for lesions showing atypical cells and increased nucleocytoplasmic ratio (black arrow) (g). SK, seborrheic keratosis.

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Figure 5: A 52-year-old male patient with multiple SK on his face, head and body several years ago; in addition, 2 years ago he had a lesion that was confirmed as basosquamous carcinoma by carrying out a biopsy (a, b, g, i, j); the dermoscopy image. The histopathology showing basaloid cells are atypically larger, mitotically more active (yellow arrow), and with increase apoptotic nuclei, transition zone with increase intermediate cells, fibroblast, stroma, squamoid cells with cytoplasmic keratinization, dyskeratotic cells, frequent mitosis. H&E, ×40 (k). SK, seborrheic keratosis.

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Figure 6: A 75-year-old male patient with multiple seborrheic keratosis on the back and face 10 years ago, and a year ago one of these lesions of the back enlarged and gave the appearance as in figure (a); dermoscopy showing multiple blue gray clods (red arrow), linear thick blood vessels (yellow arrow) and structureless area; by carrying out biopsy it was found to be pigmented BCC (b– d). Histopathologic examination shows focal ulceration of the epidermis. The dermis is infiltrated with sheets, clusters and nests of malignant basaloid cells with peripheral palisading (yellow arrow). The
tumor clusters are surrounded with immature stroma with the presence of melanin pigment (black arrow). Both lateral and deep margins of excision are infi ltrated with tumor cells. H&E, ×40 (e). BCC, basal cell carcinoma.


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Clinical types of seborrheic keratosis

Following types of SKs were diagnosed in our patients: stucco keratosis (n = 35), dermatosis papulosa nigra (DPN) (n = 8), flat SK (n = 5) and melanoacanthoma (n = 2).

Dermoscopic findings of studied cases

Following is a list of dermoscopic findings in the present study: sharp demarcated borders (n = 41, 82%), comedo-like openings (n = 25, 50.0%), cerebriform pattern (n = 19, 38.0%), moth-eaten borders (n = 17, 34.0%), crypts (n = 15, 30.0%), milia-like cysts (n = 13, 26%), fissure and ridges (n = 8, 16.0%), fat fingers (n = 2, 4.0%), network-like structures (n = 1, 2.0%) and typical hairpin blood vessels (n = 1, 0.2%) [Table 1].
Table 1: Dermoscopic findings of the studied cases

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Different clinical types of SK by dermatoscope

Following were the different clinical types of SK detected by using a dermatoscope: stucco keratosis (n = 35), in which lesions showed sharp demarcated borders (n = 30, 8.7%), comedo-like openings (n = 18, 51.4%), cerebriform (n = 11, 31.4%), moth-eaten borders (n = 12, 34.3%), crypts (n = 10, 28.6%), milia-like cysts (n = 7, 20.0%), fissures and ridges (n = 5, 14.3%), fat fingers (n = 1, 2.9%), network-like structures (n = 1, 2.9%) and typical hairpin blood vessles (n = 1, 2, 9%) [Table 2].
Table 2: Comparison between types regarding clinical findings

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DPN (n = 8), in which lesions showed sharp demarcated borders (n = 5, 62.5%), comedo-like openings (n = 2, 25.0%), cerebriform (n = 4, 50.0%), moth-eaten borders (n = 3, 37.5%), crypts (n = 2, 25.0%), milia-like cysts (n = 1, 12.5%), and fissures and ridges, fat finger, network-like structure, and typical hairpin blood vessles (0.0%) [Table 2].

Melanoacanthoma (n = 2), in which lesions showed sharp demarcation borders (n = 2, 100%), comedo-like openings (n = 2, 100%), cerebriform (n = 2, 100%), moth-eaten borders (n = 1, 50.0%), crypts (n = 1, 50.0%), milia-like cysts (n = 1, 50.0%), fissures (n = 1, 50.0%), and fat finger, network-like structure, and typical hairpin blood vessles (n = 0, 0.0%) [Table 2].

Flat SK (n = 5), in which lesions showed sharp demarcated borders (n = 4, 80.0%), comedo-like openings (n = 3, 60.0%), cerebriform (n = 2, 40.0%), moth-eaten borders (n = 1, 20.0%), crypts (n = 2, 40.0%), milia-like cysts (n = 4, 80%), fissures and ridges (n = 2, 40%), fat finger (n = 1, 20%), and network-like structure and typical hairpin blood vessles (n = 0, 0.0%) [Table 2].

Clinical characteristics of suspicious lesions

Following clinical characteristics of suspicious lesions were found in the present study: inflamed (n = 2, 22.2%), irritated (n = 2, 22.2%), discharged (n = 1, 11.1%), itchy (n = 2, 22.2%) and darkly pigmented (n = 2, 22.2%) [Table 2].

Dermoscopic findings of suspicious lesions

In our study, dermoscopic features of suspicious lesions showed structureless area, blue gray and yellow clods (n = 1, 11.1%); blue gray clods, linear thick blood vessels and structureless area (n = 1, 11.1%); and comedo-like opening, milia-like cyst, sharp dermarcated border, moth-eaten border, fissures and hairpin blood vessels (n = 7, 77.8%).

In our study dermoscopy criteria of suspicious lesions (n = 9, 18%) was diagnostic by 22.2% to tumour that showing by dermoscopy structureless area, blue gray clod (n = 1, 11.1%),and structureless area yellow clods and blue gray clods (n = 1, 11.1%) and (n = 7, 77.8%) showing sharp demarcation border, comedo-like opening, moth-eaten border, milia-like cyst, fissures and ridges [Table 3].
Table 3: Clinical findings of suspicious lesions among studied cases

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Histopathological findings of suspicious lesions

Following were the biopsy findings of suspicious lesions: SK (n = 7, 77.8%) and basal cell carcinoma (BCC) (n = 2, 22.2%) [Table 4].
Table 4: Biopsy findings among biopsied lesions

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Following were the types of BCC found through biopsy: basosquamous carcinoma (n = 1, 50.0%) and pigmented BCC (n = 1, 50.0%) [Table 5].
Table 5: Types of basal cell carcinoma found by biopsy

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[Table 1] showed that the most frequent feature of lesions by using dermoscopy was sharp demarcated borders, followed by comedo-like opening and cribriform pattern. Network-like structures and typical hairpin blood vessels were the least frequent.

[Table 4] showed that about two-thirds of the biopsied lesions were SK.


  Discussion Top


SK is a benign papilloma of the skin characterized by its typical morphology and is a characteristic sign of aged skin [5].

There are many clinical variants of SK: DPN, pedunculated seborrheic keratoses, flat seborrheic keratoses and stucco keratosis [6]. It is usually diagnosed on clinical basis, but in a certain percentage of cases differentiating it from malignant melanoma becomes difficult.

Dermoscopic features and patterns seen in SK often prove valuable in differentiating seborrheic keratoses from other lesions, including melanoma, as it is a noninvasive technique that allows microscopic visualization of subsurface skin structures not visible to the naked eye. However, irritated or traumatized seborrheic keratoses can mimic melanoma or squamous cell carcinoma. In these cases the history of trauma or the presence of typical criteria for seborrheic keratoses in another part of the lesion might be comforting.

It is important to remember that skin cancer can develop within SK. With the help of a dermatoscope an isolated suspicious foci within larger lesions can be determined easily, and thus the use of dermatoscope does not require additional expense to the patient for invasive procedures, such as biopsy. When a biopsy is needed, it is carried out for isolated suspicious foci within larger lesions [7].

The classic dermatoscopic criteria for SK (milia-like cysts and comedo-like openings) have a high prevalence but the use of additional dermatoscopic criteria, such as fissures, hairpin blood vessels, sharp demarcation, and moth-eaten borders, improves the diagnostic accuracy. In addition, the proper identification of pigment network and network-like structures is important for the correct diagnosis [8].

In the current study we aimed to determine the role of dermoscopy in diagnosing and differentiating different types of SK to decrease diagnostic biopsies and detect suspicious lesions, and to confirm the diagnosis through histopathology.

Dermoscopic criteria in the present study revealed that 41 lesions (82%) had sharp demarcated borders, 25 lesions (50%) had comedo-like openings, 19 lesions (38%) had cerebriform pattern, 17 lesions (34%) had moth-eaten borders, 15 lesions (30%) had crypts, 13 lesions (26%) had milia-like cysts, fissures, and ridges, eight lesions (16%) fat finger, two lesions (4%), network-like structures one lesions (2%), and one lesion had typical hairpin blood vessels (2%).

These findings come in disagreement with those of a study by Braun et al. [9], who conducted a study on dermoscopic criteria of SK and found that comedo-like openings were found in 71%, milia-like cyst in 66%, moth-eaten border in 46%, sharp demarcated border in 90%, hairpin vessels in 63%, network-like structures in 46%, and fissures in 61% of the lesions. This may be attributed to different number of studied cases or the different racial backgrounds of the patients.

In our study, sharp demarcated border, comedo-like openings, cerebriform pattern, moth-eaten borders and milia-like cysts were the most common diagnostic criteria for the identification of the majority of SK, and other criteria (fissures, fat finger, network-like structures, hairpin blood vessels) decreased the risk for misclassification of SK and thus had the potential to improve the diagnostic accuracy.

In our study, the most common dermoscopic findings for different types of SK (stucco, DPN, melanoacanthoma, flat type) were sharp demarcated border, comedo-like opening, milia-like cysts, moth-eaten borders and cribriform pattern. It was noticed that hairpin blood vessels and fat finger appeared in nine lesions of flat type SK. Overall, 18% of our patients underwent biopsy because lesions in these cases were diagnosticly doubtful and could therefore be considered as critical lesions [inflamed (n = 2, 22.2%), irritated (n = 2, 22.2%), discharged (n = 1, 11.1%), itchy (n = 2, 22.2%), and darkly pigmented (n = 2, 22.2%)].

In our study, dermoscopic features of suspicious lesions showed structureless areas, blue gray and yellow clods (n = 1, 11.1%); blue gray clods, linear thick blood vessels and structureless area (n = 1, 11.1%); and comedo-like openings, milia-like cysts, sharp dermarcated borders, moth-eaten borders, fissures and hairpin blood vessels (n = 7, 77.8%).

In our study, dermoscopic criteria of suspicious lesions (n = 9, 18%) was diagnostic by 22.2% to tumour that, by using dermoscopy, showed structureless area, blue gray clods (n = 1, 11.1%); structureless area yellow clods and blue gray clods (n = 1, 11.1%); and sharp demarcated borders, comedo-like openings, moth-eaten borders, milia-like cysts, and fissures and ridges (n = 7, 77.8%).

In our study 22.2% of the biopsied cases were BCC and 77.8% were SK.

Zaballos et al. [4] carried out a study that showed dermoscopy improving the recognition of the tumour. In 19 cases, a total of 52.6% of lesions were clinically diagnosed without dermoscopy as a SK with the prognostic and therapeutic considerations that this entails. Only in 31.6% of the cases was the diagnosis correct without dermoscopy. However, with aid of dermoscopy 100% of the cases were correctly diagnosed as compound tumours.

In our study, types of BCC found by carrying out biopsy were as follows: 50.0% pigmented BCC on top of SK and 50.0% basisquamous carcinoma.

SK and BCC have characteristic dermoscopic features and a study by Pehamberger et al. [3] reported that dermoscopy increases the diagnostic accuracy of BCC from 58 to 84% and SK from 62 to 77%. The presence of fissures and ridges, multiple milia-like cysts, comedo-like openings, light-brown fingerprint-like structures, moth-eaten areas and hairpin vessels surrounded by white halo suggests a dermoscopic diagnosis of SK [2].

In contrast, the presence of maple leaf-like areas, spoke-wheel areas, large blue-grey ovoid nests, multiple blue-grey globules, arborising telangiectasias and ulceration with the absence of a pigment network are dermoscopic features of BCC. Using this model, a study by Menzies et al. [10] obtained a sensitivity of 97% for the dermoscopic diagnosis of BCC and a specificity of 93% for invasive melanomas and 92% for benign pigmented skin lesions. Later, a study by Peris et al. [11] confirmed the reproducibility of the method proposed in a study by Menzies and colleagues for the dermoscopic diagnosis of pigmented BCC.

We believe that dermoscopy could be a reliable and valid diagnostic tool that can differentiate pigmented skin lesions by the help of specific criteria for each lesion, and it is a useful tool for early recognition of malignant melanoma. Patients with SK can be followed up on the basis of specific dermoscopic criteria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Roberti V, Devirgiliis V, Curzio M, Gobbi S, Coppola R, Calvieri S, Panasiti V. The blue globular pattern in dermoscopy. Dermatology 2013; 226 :260-266.  Back to cited text no. 1
    
2.
Argenziano G, Soyer HP, Chimenti S, Talamini R, Corona R, Sera F, et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the internet. J Am Acad Dermatol 2003; 48 :679-693.  Back to cited text no. 2
    
3.
Pehamberger H, Binder M, Steiner A, Wolff K. In vivo epiluminescence microscopy: improvement of early diagnosis of melanoma. J Invest Dermatol 1993; 100 :356S-362S.  Back to cited text no. 3
    
4.
Zaballos P, Banuls J, Cabo H. Dermoscopy improves the recognition of benign-malignant compound tumors. Br J Dermatol 2012; 153 :653-656.  Back to cited text no. 4
    
5.
Pierson D, Bandel C, Ehrig T, et al. Benign epidermal tumors and proliferations. In: Bologna JL, Jorizzo JL, Raphini RP, et al. eds Dermatology. Toronto, Canada: Mosby; 2002. 1697-1717.  Back to cited text no. 5
    
6.
Noiles K, Vender R. Are all seborrheic keratoses benign? Review of the typical lesion and its variants. J Cutan Med Surg 2008: 12 :203-210.  Back to cited text no. 6
    
7.
Marghoob AA, Braun RP, Malvehy J. Atlas of dermoscopy book 2012; p: 3,5,10 Informa  Back to cited text no. 7
    
8.
Takenouchi T. Key points in dermoscopic diagnosis of basal cell carcinoma and seborrheic keratosis in Japanese. J Dermatol 2011; 38 :59-65.  Back to cited text no. 8
    
9.
Braun RP, Rabinovitz HS, Krischer J, Kreusch J, Oliviero M, Naldi L, et al. Dermoscopy of pigmented seborrheic keratosis: a morphological study. Arch Dermatol 2002; 138 :1556-1560.  Back to cited text no. 9
    
10.
Menzies SW, Westerhoff K, Rabinovitz H, Kopf AW, McCarthy WH, Katz B. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000; 136 :1012-1016.  Back to cited text no. 10
    
11.
Peris K, Altobelli E, Ferrari A, et al. Inter observer agreement on dermoscopic features of pigmented basal cell carcinoma. Dermatol Surg 2002; 2:643-645.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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