• Users Online: 882
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 42  |  Issue : 3  |  Page : 174-182

Role of dermoscopy in diagnosing and differentiating seborrheic keratoses: a case study of 100 patients


Deparment of Skin (DVL), Goa Medical College, Goa, India

Date of Submission17-Sep-2021
Date of Acceptance18-Nov-2021
Date of Web Publication01-Sep-2022

Correspondence Address:
MD (Skin) Aswath Rajan
633c, Thirumalai Nagar, Near TSP Camp, Palani 624601, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejdv.ejdv_39_21

Rights and Permissions
  Abstract 


Background Seborrheic keratosis is one of the most common benign epidermal tumors seen in elderly individuals. It has slow growth and presents with a varied degree of pigmentation in skin color closely resembling many other pigmented dermatoses. Dermoscopy, a noninvasive technique, could increase the accuracy of diagnosis and can differentiate it from various closest mimickers and malignancies.
Aim This study aims to describe the various dermoscopic features of seborrheic keratosis in a series of cases.
Patients and methods A hospital-based, descriptive study was conducted over 12 months from January 2018 to December 2018 in the Department of Dermatology, a tertiary-care center. A total of 100 patients were selected and evaluated in a prestructured proforma concerning age, sex, site of lesion, number and duration, and associated comorbidities. The lesion is observed on dermoscopy, and the dermoscopic patterns were then documented and analyzed.
Result Among a total of 100 (32%) cases, the most common age group was between 41 and 50 years with females (52%) outnumbering males (48%). The most common site was the face (38%), and the common morphology was plaque (60%). Sign of Leser-Trélat was observed in five patients of which three were associated with malignancy that includes two lymphomas and one breast carcinoma. The color on dermoscopy was predominant dark brown (43%) and brownish-black (32%). The common element was clod (39%) and combined clod and dots (18%). More than three colors and more than two elements in a single lesion were observed in 15 and 11% of cases, respectively. The dermoscopic clues of seborrheic keratosis with highest to lowest prevalence were cerebriform pattern (76%), sharp demarcation (64%), comedone-like opening (56%), milia-like cyst (54%), mica-like scales (52%), moth-eaten border (46%), jelly sign (40%), fingerprint-like pattern (40%), fat fingers (36%), peripheral globules/network (34%), coral-like structure (26%), papillary structures (26%), irregular globules (12%), irregular opaque brown pigmentation (12%), and yellow-orange areas (3%). The flat seborrheic keratosis predominantly showed an irregular network-like structure, fat fingers, milia-like cyst, and accentuation of two adjacent perifollicular pigmentations forming a double ring-like structure (16%). The raised lesions predominantly showed fissures/ridges (cerebriform pattern), exophytic papillary structures, opaque pigmentation, and a mica-like pattern. Ten lesions were misinterpreted as seborrheic keratosis clinically and on dermoscopy were verruca vulgaris (2/10, 20%), melanocytic nevus (3/10, 30%), and basal cell carcinoma (5/10, 50%), which were confirmed on histopathology.
Conclusion The study emphasizes the use of dermoscopy in seborrheic keratosis to improve the clinical accuracy of diagnosis and also to differentiate from its common mimickers.

Keywords: BCC, comedone opening, dermoscopy, milia cyst, nevus, seborrheic keratosis


How to cite this article:
Rajan A, Shukla P, Pai VV. Role of dermoscopy in diagnosing and differentiating seborrheic keratoses: a case study of 100 patients. Egypt J Dermatol Venerol 2022;42:174-82

How to cite this URL:
Rajan A, Shukla P, Pai VV. Role of dermoscopy in diagnosing and differentiating seborrheic keratoses: a case study of 100 patients. Egypt J Dermatol Venerol [serial online] 2022 [cited 2023 Jan 27];42:174-82. Available from: http://www.ejdv.eg.net/text.asp?2022/42/3/174/354681




  Introduction Top


Seborrheic keratosis is one of the common benign epidermal skin lesions seen by dermatologists in their clinical practice. Though asymptomatic, it is of great cosmetic concern as it is mostly seen on the face and the upper trunk.

Clinically they present as sharply demarcated circumscribed macules, brown to black ([Figure 1]) that later becomes exophytic with a verrucous or papillomatous surface and the classical ‘stuck-on appearance’ ([Figure 2]). They are usually multiple and, on the back, they are mostly distributed in a ‘Christmas tree pattern’ [1].
Figure 1 Clinical photograph of early seborrheic keratosis shows sharply defined and slightly raised brown oval papules or polypoidal lesions with a velvety stuck-on appearance.

Click here to view
Figure 2 Clinical photograph of late seborrheic keratosis shows sharply defined dark brown to black, raised oval papules. or polypoidal lesions with velvety stuck-on appearance.

Click here to view


Dermoscopy is a noninvasive and in-vivo diagnostic tool that helps to identify and document various epidermal and subepidermal findings that are unique to seborrheic keratosis; hence, it improves the clinical accuracy and also helps to differentiate it from the possible differential diagnosis and malignancy. The single lesions do possess a diagnostic challenge to distinguish from its closest mimickers such as verruca vulgaris, melanocytic nevus, basal cell carcinoma, etc. [2].

This study is conducted to analyze the epidemiology, dermoscopic pattern, and clues of seborrheic keratosis and also to distinguish it from the closest mimickers.


  Patients and methods Top


This is a descriptive study conducted in the Department of Dermatology, a tertiary-care center over 12 months between January 2018 and December 2018. Ethical clearance was obtained from the committee members. All the patients presenting to the OPD with clinical consideration of seborrheic keratosis and willing to give informed consent were included in the study. The patient’s profile such as age, sex, occupation, duration, and associated comorbidities were noted in the performed proforma. Head-to-toe general examination was carried out. All patients were subjected to detailed history and clinical examination of the lesion using a handheld magnifying lens (10×). The site, size, number of lesions, and morphology were noted. The clinical photographs were imaged using a Nikon D3400 digital camera (24.2-megapixel DX format DSLR Nikon F-mount camera). The lesion was then observed on dermoscopy using a Heine delta T20 handheld dermoscope (10×) both in polarized and nonpolarized mode, and the image was captured using Nikon D3400 connected with a special adapter. Various parameters such as color, basic element, morphology, pigment pattern, vascular pattern, and other dermoscopic clues were analyzed. Biopsy was done in all patients, and the diagnosis was confirmed with histopathological findings. Appropriate treatment is given for cosmetic purposes. The statistical analysis of the data was performed using the Statistical Package for the Social Sciences (SPSS) software, version 22 (IBM SPSS statistics, Chicago, United States).


  Results Top


A total of 100 patients were included in the study comprising females (52%) and males (48%). The common age group was between 41 and 50 years with 32% of cases, followed by 51–60 years (28%) and 61–70 years (20%). The age group interval was from 21 to 90 years with the median age of presentation being 57.53. The most common duration of the presentation was less than 1 year (46%) followed by 1–2 years (34%).

The common site of involvement was the face (38%) followed by both face and neck in 14% of cases. Other sites of involvement were scalp, back, forearm, and legs. The most common morphology was plaque (60%) followed by a combination of patch and plaque (40%). The number of lesions ranges from a single lesion to several hundreds of lesions. The size of the lesion varied from as small as 0.3 mm to 4 cm.

The most common color seen on dermoscopy was in different shades of brown with predominant dark brown (43%) and brownish-black in 32% of cases. More than three colors in a single lesion were observed in 15% of cases. The common element was clod (39%), followed by clod and dots (18%). More than two elements were observed in 11% of cases.

The dermoscopic clues of seborrheic keratosis with the highest to the lowest prevalence were cerebriform pattern (76%), sharp demarcation (64%), comedone-like opening (56%), milia-like cyst (54%) ([Figure 3]), mica-like scales (52%), moth-eaten border (46%), Jelly sign (40%), fingerprint-like pattern (40%), fat fingers (36%), peripheral globules/network (34%), coral-like structure (26%), papillary structures (26%), irregular globules (12%), irregular opaque brown pigmentation (12%), and yellow-orange areas (3%). The description of various dermoscopic patterns is depicted in [Table 1].
Figure 3 Dermoscopic image of seborrheic keratosis shows comedone-like opening with keratinous plugging (white arrows), milia-like cyst (yellow arrows), and marginal fat fingers (red circles and inlet).

Click here to view
Table 1 Dermoscopic and histopathological correlation

Click here to view


The flat seborrheic keratosis predominantly showed an irregular network forming fingerprints such as areas, fat fingers, milia-like cyst, and coral-like pattern ([Figure 4] and [Figure 5]). The early lesions also showed accentuated perifollicular and perieccrine pigmentation forming multiple ring- like structures seen in 16% of cases ([Figure 6] and [Figure 7]). The raised lesions predominantly showed fissures/ridges (cerebriform pattern), exophytic papillary structures, opaque pigmentation, and a mica-like pattern ([Figure 8],[Figure 9],[Figure 10]).
Figure 4 Dermoscopic image of early seborrheic keratosis showing a fingerprint-like pattern (white arrows).

Click here to view
Figure 5 Dermoscopic image of early seborrheic keratosis showing brown globules in a coral-like pattern (hyperpigmented clods with hypopigmented areas/meshwork in-between).

Click here to view
Figure 6 (a) Dermoscopic image of early seborrheic keratosis showing the cluster of brown globules (circles) of different sizes and shapes, fat fingers. (b) Dermoscopic image of early seborrheic keratosis showing perifollicular and perieccrine pigmentation forming multiple ring- like structure and multiple scattered brown clods obliterating the ductal opening.

Click here to view
Figure 7 Dermoscopic image of seborrheic keratosis showing comedone-like opening (white arrow), mica-like scales (yellow arrows) with preexisting nevi (red arrow).

Click here to view
Figure 8 Clinical image of seborrheic keratosis lesion along the margin of the eyelid.

Click here to view
Figure 9 Dermoscopic image of seborrheic keratosis lesion along the margin of the eyelid shows gray-blue globules.

Click here to view
Figure 10 Dermoscopic image of seborrheic keratosis lesion shows exophytic papillary structures.

Click here to view


The sign of Leser-Trélat was observed in five patients of which three was associated with malignancy including two lymphomas and one breast carcinoma ([Figure 11],[Figure 12],[Figure 13]).
Figure 11 Clinical image of sign of Lesser-Trelat, an eruption of multiple pruritic seborrheic keratosis that is associated with breast carcinoma in this patient.

Click here to view
Figure 12 Dermoscopic image showing cerebriform pattern with comedonal opening covered with keratinous plugging and few papillary projections (white arrows).

Click here to view
Figure 13 Dermoscopic image showing cerebriform pattern with fissures (white arrows) and ridges.

Click here to view


Ten lesions were misinterpreted as seborrheic keratosis clinically and on dermoscopy were verruca vulgaris (2/10, 20%), melanocytic nevus (3/10, 30%), and basal cell carcinoma (5/10, 50%), which were confirmed on histopathology.


  Discussion Top


Seborrheic keratosis is the most common benign epidermal tumor and is of great cosmetical concern among patients. Though clinically it can be diagnosed based on the morphology, many of the lesions do mimic melanocytic nevus, verruca vulgaris, basal cell carcinoma, and Bowen’s disease.

Dermoscopy is a noninvasive technique used in various fields in dermatology. The basic structure/element of dermoscopy are lines, clod, dot, streak, circle, and structureless area. Melanin is an important chromophore in depicting the color of pigmented skin lesions. Depending on the concentration of melanin and its anatomic location, the color range from black to blue secondary to the Tyndall effect [3].

The earliest dermoscopic features described for seborrheic keratosis is milia-like cyst and comedone-like opening [4]. Later in the consensus Net Meeting, two-step algorithms were formulated using features such as milia-like cyst, comedone-like opening, fissures and ridges (cerebriform appearance), and light brown fingerprint-like areas [5] ([Figure 14] and [Figure 15]). Braun et al. [6] proposed additional criteria such as sharply demarcated borders, hairpin vessels, and moth-eaten borders. Other signs were crypts, jelly sign, and exophytic papillary structures. Lin et al. [7] evaluated the dermoscopic algorithm in 412 patients and concluded that multiple milia-like cyst, comedone-like opening, mica-like structure, sharp demarcation, and yellowish color had higher concordance with histopathology. These features improve sensitivity and also lowers the false positive report. The description of dermoscopic patterns and their histopathological correlation is depicted in [Table 1].
Figure 14 Dermoscopic image showing brownish clods as a coral-like pattern with fingerprint-like pattern at the margin.

Click here to view
Figure 15 Dermoscopic image of advanced seborrheic keratosis shows opaque brownish-black and greyish-blue pigmentation, irregular crypt, deep fissures (white arrow), dense keratinous plugging (yellow arrow), obliterating comedonal opening (green arrow), and milia-like cyst (red arrow).

Click here to view


In comparison of our results with a similar study, the median age of presentation is 57.53 similar to the observation made by Lin et al. [7], where the median age was 60 years. The highest prevalence of the dermoscopic clues such as multiple milia-like cyst (54%), comedone-like opening (56%), and fissures/ridges (76%) was also observed in the study by Goncharova et al. [8] and Nayak et al. [9] ([Table 2]). Sharp demarcation (64%), moth-eaten borders (46%), and mica-like structures (52%) were also observed maximum in concordance with other studies ([Table 2]). The vascular structure such as hairpin vessels and grape-like vessels were not predominantly observed in the current study, possibly due to the skin color (Fitzpatrick types 4 and 5). The accentuation of adjacent perifollicular pigmentation in many early lesions of seborrheic keratosis such as multiple ‘ring-like structures’ observed in the current study was not mentioned before in the literature ([Figure 6]b).
Table 2 Dermoscopic findings in comparison with similar studies

Click here to view


Ten lesions were misinterpreted as seborrheic keratosis clinically and on dermoscopy were verruca vulgaris (2/10, 20%), melanocytic nevus (3/10, 30%), and basal cell carcinoma (5/10, 50%), which were confirmed through histopathology.

On dermoscopy, common wart showed papillae, dotted and loop vessels, and multiple irregular hemorrhagic points. The blackish-brown dotted papillae surrounded by the lobulated white halo gives a frogspawn appearance [10] ([Figure 16] and [Figure 17]).
Figure 16 Dermoscopic image showing viral wart (inlet–clinical image).

Click here to view
Figure 17 Dermoscopic image of a viral wart after parring showing multiple pinpoint vessels.

Click here to view


The epidermal nevi can be either globular or reticular or combined. The globular nevi are characterized by different sized globules (clods) or cobblestone-like patterns with the color varying from brown, gray, and blue ([Figure 18]) [11]. Occasionally, few comedone-like openings or milia-like cysts, as well as terminal hairs, can be observed. The reticular nevi present with accentuation of the reticular network, dark brown to black color with central hyperpigmentation and fading at the margin ([Figure 19]).
Figure 18 Dermoscopic image of congenital melanocytic nevi characterized by different sized globules color varying from brown, gray, and blue (inlet–clinical image).

Click here to view
Figure 19 Reticular nevi present with accentuation of the reticular network, dark brown to black color with central hyperpigmentation and fading at the margin.

Click here to view


Verrucous epidermal nevi show the presence of large circles with various shades of brown. These brown circles are round or oval characterized by the presence of a central hypochromic region surrounded by a hyperchromic brown edge ([Figure 20]). Comedone-like opening can also be seen in some cases of nevi that correspond to the pseudohorn cyst opened to the surface ([Figure 21]). The other findings described in nevi are cerebriform and cobblestone patterns. However, they appear very uniform within the first decade, unlike seborrheic keratosis [12].
Figure 20 Dermoscopic image of verrucous epidermal nevi in a cobblestone appearance with exophytic papillary structure at the margin (white arrow), multiple comedone-like opening (black circles), brown circles (blue arrow) (inlet–clinical picture of verrucous nevi).

Click here to view
Figure 21 Dermoscopic image of verrucous epidermal nevi showing brown globules (black arrow) and comedone-like opening (white arrow).

Click here to view


The positive features of pigmented BCC include large blue-gray ovoid nests, multiple blue-gray dots and globules, leaf-like structures, spoke-wheel-like structures, arborizing telangiectasia, and ulceration [13] ([Figure 22]).
Figure 22 Dermoscopic image of BCC showing large blue-gray ovoid nests (white arrow), multiple blue-gray dots and globules (black circles), leaf-like structures (red arrow), and spoke-wheel-like structures (blue arrow).

Click here to view



  Conclusion Top


Dermoscopy is a trustworthy diagnostic tool that helps to recognize seborrheic keratosis. The certain dermoscopic pattern shows a higher sensitivity and hence aids in accurate seborrheic keratosis and hence can distinguish benign from malignant lesions. It also obviates the necessity of unnecessary biopsy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hafner C, Vogt T. Seborrheic keratosis. J Dtsch Dermatol Ges J Ger Soc Dermatol 2008; 6:664–677.  Back to cited text no. 1
    
2.
Braun RP, Rabinovitz HS, Oliviero M, Kopf AW, Saurat J-H. Dermoscopy of pigmented skin lesions. J Am Acad Dermatol 2005; 52:13.  Back to cited text no. 2
    
3.
Menzies SW, Crotty KA, Ungvar C, McCarthy WH. An atlas of surface microscopy of pigmented skin lesions. Sydney, Australia: McGraw-Hill Inc; 1996.  Back to cited text no. 3
    
4.
Argenziano G, Soyer HP, De Giorgi V, Piccolo D, Carli P, Delfino M et al. Dermoscopy-An Interactive Atlas [CD-ROM]. Milan, Italy: EDRA Medical Publishing; 2000.  Back to cited text no. 4
    
5.
Soyer HP, Argenziano G, Chimenti S, Talamini R, Corona R, Sera F et al. Consensus NetMeeting on Dermoscopy. Milan, Italy: EDRA Medical Publishing; 2001.  Back to cited text no. 5
    
6.
Braun RP, Rabinovitz HS, Krischer J, Kreusch J, Oliviero M, Naldi L, Kopf AW, Saurat JH. Dermoscopy of pigmented seborrheic keratosis. Arch Dermatol 2002; 138:1556–1560.  Back to cited text no. 6
    
7.
Lin J, Han S, Cui L, Song Z, Gao M, Yang G et al. Evaluation of dermoscopic algorithm for seborrhoeic keratosis: a prospective study in 412 patients. J Eur Acad Dermatol Venereol 2014; 28:957–962.  Back to cited text no. 7
    
8.
Goncharova Y, Attia EAS, Souid K, Vasilenko IV. Dermoscopic features of facial pigmented skin lesions. ISRN Dermatol 2013; 2013:1–7.  Back to cited text no. 8
    
9.
Nayak SS, Mehta HH, Gajjar PC, Nimbark VN. Dermoscopy of general dermatological conditions in indian population: a descriptive study. Clin Dermatol Rev 2017; 1 (no. 2):41.  Back to cited text no. 9
    
10.
Piccolo V. Update on dermoscopy and infectious skin diseases. Dermatol Pract Concept 2019; 10:e2020003.  Back to cited text no. 10
    
11.
Errichetti E, Patriarca MM, Stinco G. Dermoscopy of congenital melanocytic nevi: a ten-year follow-up study and comparative analysis with acquired melanocytic nevi arising in prepubertal age. Eur J Dermatol 2017; 27:505–510.  Back to cited text no. 11
    
12.
Carbotti M, Coppola R, Graziano A, Verona Rinati M, Paolilli FL, Zanframundo S, Panasiti V. Dermoscopy of verrucous epidermal nevus: large brown circles as a novel feature for diagnosis. Int J Dermatol 2016; 55:653–656.  Back to cited text no. 12
    
13.
Lallas A, Tzellos T, Kyrgidis A, Apalla Z, Zalaudek I, Karatolias A et al. Accuracy of dermoscopic criteria for discriminating superficial from other subtypes of basal cell carcinoma. J Am Acad Dermatol 2014; 70:303–311.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed817    
    Printed46    
    Emailed0    
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]