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progression of malignant melanoma with ulcerated nodule.
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Malignant melanoma in situ on sun-damaged skin of cheek, approximately 18 mm in largest diameter.
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color variegation of early malignant melanoma. Irregularly marginated pigmented lesion and prominent pinkish-white components are indicative of spontaneous partial regression.
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color variegation of malignant melanoma. Note the pink-red component at the lower margin of the lesion.
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A 3.5-cm pink, pearly irregularly shaped plaque was noted over the right temple, with light brown crust along the edges and a hyperpigmented focus at the inferior aspect.
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Peripheral atypical pigmented network structure (more marked on the right of the lesion), brownish streaks in the central area and right periphery, a peripheral area with a black blotch and some globular structures, an amorphous area with a pseudofollicular opening and pseudocysts on the left of the lesion, beyond the veil in the center of the lesion
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On the left upper extremity, there is an approximately one-centimeter tender, hyperkeratotic, brown, verrucous stuck-on plaque.
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nodular lesion located on forehead. This clinical form, taken together with the papular form, was the most frequent in our case-control study, particularly in the head and neck area.
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Atypical pigmented network
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Atypical pigmented network
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Blue-white Veil
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Blue-white Veil
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Irregular pigmentation
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irregular dots and globules
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Irregular streaks
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Regression structures
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atypical vessel
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atypical vessel
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A 7 mm pigmented macule with foci of hyperpigmentation: an atypical broad pigmented network with peripheral asymmetrical globules is seen on dermoscopy
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An 8 mm irregular pigmented macule with an eccentric focus of hyperpigmentation: the eccentric focus of pigmentation is composed of an atypical broad pigmented network, corresponding to melanoma in situ
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An 8 mm irregular pigmented macule with an eccentric focus of hyperpigmentation: an atypical pigment network, irregular dots and globules, blue–white veil inferiorly and variable areas of hyper- and hypopigmentation are seen in this melanoma with Breslow thickness 0.4 mm
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An 8 mm suspicious irregular pigmented macule: multiple dermoscopic and regression structures are seen in this melanoma with Breslow thickness 0.8 mm
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1.3 mm Breslow thickness melanoma with irregular globules, atypical vessels and a blue–white veil
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The hypopigmented component of this 1.5 mm Breslow thickness melanoma shows localised irregular vessels
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This 16 mm Breslow thickness melanoma has poorly visible blood vessels through background granular brown pigmentation
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A 4 mm diameter, 0.3 mm Breslow thickness melanoma presenting as a geographical/angular-shaped, uniformly pigmented macule, with preserved skin surface markings; dermoscopy shows homogeneous pigmentation, few hyperpigmented dots and streaks
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A 10 mm diameter, 0.7 mm Breslow thickness melanoma, irregularly shaped pigmented macule; dermoscopy shows a multicomponent pattern with asymmetric structures and a focal blue–white veil
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A hyperpigmented melanoma with a superficial black network with black dots and globules, and peripheral pigmented brown globules
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A hyperpigmented melanoma with a superficial black network, with black dots and globules and asymmetrical pigmented streaks
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A melanoma (Breslow 0.35 mm) with light brown, pink and dark brown bands: dermoscopy shows the junction between vascular features (pinks) and the dark browns of the atypical network
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A melanoma (Breslow 1.0 mm) with palpable component of hyperpigmentation corresponding to the area of dermal blue pigmentation on dermoscopy
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A light brown macule with a new pink plaque component: dotted and linear irregular vessels are seen within the invasive component of this 0.6 mm Breslow thickness melanoma
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A light brown macule with a new pink papular component: dotted and linear irregular vessels are seen in this 0.8 mm Breslow thickness melanoma
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A pigmented macule with irregular pigmented blotches and globules on dermoscopy in a 0.4 mm Breslow thickness SSMM
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A large, variably pigmented patch with multiple dermoscopic structures in this 0.8 mm Breslow thickness SSMM
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A 3.8 mm nodular melanoma with variably pigmented brown pseudo-lacunes
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A 6.5 mm hyper- and hypopigmented nodular melanoma with homogeneous pigmentation, blue–white veil and irregular vessels
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In hypopigmented nodular melanoma, linear irregular and polymorphous vessels predominate. Pseudo-lacunes may be present; however, they may be difficult to visualise due to the lack of pigmentation. A 2.6 mm hypomelanotic nodular melanoma with multiple polymorphous vessels and hypopigmented pseudo-lacunes
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Amelanotic nodular melanoma may mimic benign vascular tumours including pyogenic granulomas. Always confirm diagnosis with histology.A 6.5 mm amelanotic nodular melanoma with ulceration and polymorphous vessels
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A 0.8 mm naevoid melanoma with ill-defined brown pigmentation and polymorphous vessels
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A 0.8 mm SSMM with ill-defined shades of brown–grey homogeneous pigmentation
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A 0.8 mm SSMM with ill-defined shades of brown–grey homogeneous pigmentation
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A 0.2 mm Breslow thickness melanoma with irregular streaks at one polar end
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A 0.3 mm Breslow thickness melanoma with irregular dots and globules and regression structures
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The development of eccentric hyperpigmentation is a very important clinical feature for melanoma. This pigmentation may be due to a focus of, or combination of, an atypical network, irregular globules or irregular pigmented blotches.A 0.3 mm Breslow thickness melanoma with an eccentric atypical network
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A 0.2 mm Breslow thickness melanoma with eccentric pigmentation, globules and streaks
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A brown plaque with irregular globules and blue–white veil centrally on dermoscopy in this localised cutaneous deposit from melanoma on the calf
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Melanoma in situ with a well-defined focal negative pigmented network
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A 0.25 mm SSMM with a feint diffuse negative pigmented network
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A variably pigmented plaque: dermoscopy shows focal blue and white regression structures in this 0.65 mm Breslow thickness melanoma
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A large variably pigmented patch with hypopigmentation developing superiorly and inferolaterally: dermoscopy shows extensive regression and removal of melanocytic pigmentation in this 0.8 mm Breslow thickness melanoma
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Melanoma in situ with atypical pigmented network
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0.85 mm Breslow thickness SSMM with an atypical pigmented network and extensive regression seen clinically and dermoscopically
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1.7 mm Breslow thickness melanoma with atypical vessels seen on dermoscopy
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Images of early malignant melanomas to show major features: irregular pigmentation and irregular borders. Left = Early melanoma (0.8mm). Right = Early melanoma (1.0mm)
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A pigmented lesion showing atypical pigment network (2 points), brown-black blotches (1 point) and a regression area (1 point). The total score is 4 and indicates a suspicious lesion. Histopathologic diagnosis: melanoma (Breslow thickness: 1 mm)
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This lesion is characterized by pseudopods at bottom right (1 point), atypical network (2 points) and blue-white veil in the center (2 points). The total score is 5. Histopathologic diagnosis: melanoma (Breslow thickness: 0.8 mm)
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Irregular brown globules are visible at the periphery (1 point) and blue-whitish structures in the center (2 points). The total score is 3. Histopathologic diagnosis: melanoma (Breslow thickness: 1.3 mm)
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Dermoscopically, the lesion shows peppering in the center (1 point), atypical network (2 points) and irregular globules at the periphery (1 point). The total score is 4. Histopathologic diagnosis: melanoma in situ.
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This lesion presents exclusively regression structures and should be biopsied. Histopathologic diagnosis: melanoma in situ.
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This lesion is characterized by irregular vessels and a central regression area. The final total score is 3. Histopathologic examination: melanoma (Breslow thickness: 0.3 mm)
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This pigmented lesion, clinically resembling a dermal nevus, shows at dermoscopic examination blue-white veil in center, brown-black globules and whitish irregular lines. The lack of correlation between the clinical and dermoscopic features imposes the excision. Histopathologic diagnosis: melanoma (Breslow thickness: 0.9 mm)
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Prominent (hyperpigmented or broad) and irregular network Histological Correlates Hyperpigmented or broadened rete ridges with irregular shape or distribution Sample Lesion Irregular and prominent (atypical) pigment network (white arrow) (7-point score: 2) streaks (black arrowhead) (score: 1)
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Definition Prominent (hyperpigmented or broad) and irregular network Histological Correlates Hyperpigmented or broadened rete ridges with irregular shape or distribution Sample Lesion Irregular, but discrete, pigment network (score: 0) Regression pattern (peppering within depigmented areas, asterisk) The lesion is asymmetrical , with 4 colors and 3 dermoscopic structures irregular dots and globules (black arrow) (score: 1) Atypical Nevus (original magnification 10x) TOTAL SCORE: 1
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Irregular, confluent, gray-blue to whitish blue diffuse pigmentation not associated with red-blue lacunes or maple leaf pigmentation Histological Correlates Pigmented melanophages or melanocytes of midreticular dermis location Irregular, confluent, gray-blue to whitish blue diffuse pigmentation not associated with red-blue lacunes or maple leaf pigmentation Histological Correlates Pigmented melanophages or melanocytes of midreticular dermis location Sample Lesion with a prevalence of gray-blue areas (curved black arrow) (score: 2) An atypical pigment network (white arrow streaks (black arrowhead) blotches (white arrowhead) irregular dots and globules (black arrow) Cutaneous melanoma, 1.0 mm thick (original magnification 10x) TOTAL SCORE: 7
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Linear, dotted, or globular red structures irregularly distributed outside areas of regression and associated with other melanocytic pigment patterns Histological Correlates Neovascularization or vascularized nests of amelanotic cells Sample Lesion Atypical (dotted and globular) vascular pattern (long black arrowheads) (score: 2) Gray-blue areas (curved black arrow) treaks (short black arrowhead) Cutaneous melanoma, 0.8 mm thick (original magnification 10x) TOTAL SCORE: 5
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Linear, dotted, or globular red structures irregularly distributed outside areas of regression and associated with other melanocytic pigment patterns Histological Correlates Neovascularization or vascularized nests of amelanotic cells Sample Lesion Commalike vessels, commonly associated with dermal papillae in compound and dermal nevi(black arrowhead) (score: 0) Compound melanocytic nevus (original magnification 10x) TOTAL SCORE: 5
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Radially and asymmetrically arranged linear or bulbous extensions at the edge of the lesion Histological Correlates Confluent radial junctional nests of melanocytes Sample Lesion Streaks (black arrowhead) Irregular dots and globules (thin black arrow) Regression pattern consists of white areas (asterisk) and peppering (thick black arrow) (score: 1) Cutaneous melanoma, 0.6 mm thick (original magnification 10x) TOTAL SCORE: 3
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Brown, gray, and black areas of diffuse pigmentation with irregular shape or distribution and abrupt end Histological Correlates Hyperpigmentation throughout all levels of the epidermis or upper dermis (in melanocytes or melanophages) Sample Lesion Blotches (white arrowhead) Presence of atypical pigment network (white arrow) Relatively symmetrical lesion with abrupt cutoff of pigment pattern, 3 colors, and 4 structures streaks (black arrowhead) Cutaneous melanoma, 0.3 mm thick (original magnification 10x) TOTAL SCORE: 4
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Black, brown, or blue round structures irregularly distributed within the lesion Histological Correlates Aggregates of pigment of stratum corneum, junctional, or dermis location Sample Lesion Irregular dots and globules (black arrows) Blotches (white arrowhead) Streaks (black arrowhead Regression pattern (white areas, thick black arrows) Two lesions with similar silhouettes and distribution of colors and structures (see next page) Compound melanocytic nevus (original magnification 10x) TOTAL SCORE: 2
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Black, brown, or blue round structures irregularly distributed within the lesion Histological Correlates Aggregates of pigment of stratum corneum, junctional, or dermis location Sample Lesion Irregular dots and globules (black arrows) Blotches (white arrowhead) Streaks (black arrowhead Regression pattern (white areas, thick black arrows) Two lesions with similar silhouettes and distribution of colors and structures (see previous page) Cutaneous melanoma, 0.45 mm thick (original magnification 10x) TOTAL SCORE: 2
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White scarlike depigmentation or "peppering" (speckled multiple blue-gray dots within a hypodepigmented area)irregularly distributed within the lesion Histological Correlates Areas of loss of pigmentation and fibroplasia, with scattered dermal melanophages Sample Lesion Regression pattern (black arrows) Irregular, discrete pigment network The lesion is asymmetrical, with abrupt cutoff of pigment pattern, 4 colors, and 3 dermoscopic structures Atypical melanocytic nevus (original magnification 10x) TOTAL SCORE: 1
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A 49-year-old woman, with phototype I skin with no previous family or personal history of melanoma, presented to our department for a total skin check-up. The patient had numerous solar lentigines. Upon examination, a 9 × 4-mm brown irregular macule on the right deltoid region was detected. The dermoscopy showed apparent reticular pigmented pattern, along with some pigmented dots and a structureless central area with white-grey structures. Left panel: Clinical presentation. Irregularly pigmented macule on the shoulder. Multiple solar lentigos on the surrounding skin. Right panels: Dermoscopic image of the lesion (Fotofinder® dermoscope, 10×). The whole lesion couldn’t be included in a single image, hence it is depicted in two panels. An excisional biopsy was performed. Histopathological study showed atypical melanocytes with pagetoid epidermal extension, confined to the epidermis, and intense elastosis on the surrounding dermis.
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A 60-year-old woman, with phototype III skin and with no previous family or personal history of melanoma, presented to our department for a total skin check-up. One of his relatives, who was a physician, detected a 1-mm dark pigmented macule on the right arm that had been previously unnoticed by the patient. The patient had a moderate number of melanocytic nevi, predominantly macular. 10×-magnification dermoscopic imaging showed homogeneous pigmentation. 40×-magnification dermoscopic showed a central pigmented dark blotch, and surrounding pigmented dots and apparent peripheral streaks.Clinical presentation. Minute darkly pigmented lesion on the lateral aspect of the right arm. Other lighter and equally small pigmented lesions on the surrounding skin.
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the attending dermatologist noted a tiny, approximately 3 × 2 mm, dark brown macule lateral to his left orbit. On further questioning, the patient revealed that the spot had been first noticed 4 years earlier, after a post-traumatic contusion had healed. Dermoscopy showed multiple, white, featureless areas throughout the lesion, with dots around the periphery and clods in its central area.
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central white
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A 52-year-old woman, skin phototype III, presented with a 6-month history of a rapidly-growing nodule on the left leg (Fig. 12.1). She denied any previous local trauma or insect bite, as well as history of skin cancer. Clinical inspection revealed a brown patch with irregular and poorly defined borders, approximately 2.5 cm, with a 2 cm superimposed black and ulcerated nodule, while dermoscopy showed a central structureless pink and ulcerated area, surrounded by a yellowish area. There were also shiny white linear structures, areas of superficial brown crusts, polymorphous vessels and a peripheral pigment network (Fig. 12.2). The diagnosis of melanoma was considered. A fast-growing and ulcerated nodule corresponding to vertical growth from a superficial spreading melanoma (adjacent brown patch). The lesion was immediately excised. Histologic examination revealed a nodular lesion occupying the entire dermis and hypodermis, relatively well circumscribed, and composed of spindle cells, histiocytic cells and multinucleated giant cells. There was xantomization and hemosiderin deposition in the histiocyte’s cytoplasm (Fig. 12.3). A final diagnosis of a hemosiderotic dermatofibroma was made.
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A 90-years-old patient underwent a surgery for a nodule on the vertex with the outcome of non-ulcered nodular melanoma, which was dermis-infiltrating with 2.9 mm Breslow. Associated to the nodular component there was an extended pigmented lesion
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A 45-year-old female attended the Dermatology Clinic in 2014 for a pigmentary tumor on the antero-lateral aspect of the right arm. She noticed the change of a preexisting “brown spot” for the last two years (Clinical images: Fig. 18.1 and dermoscopy: Fig. 18.2). During the last 12 months, the patient noticed the apparition of the dark and blue pigmentations, of a small nodule and the increase in size of the tumor. Her medical history revealed an invasive ductal carcinoma breast cancer type G3 that was diagnosed in 2008
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An 58-year-old female patient came for a preventive exam in a screening campaign for early diagnosis of melanoma. She pointed out the lesion on her arm, unable to determine the duration of the lesion. Her personal and family history for cutaneous malignances were negative. Previously, in her youth, she had unprotected UV exposure during summer months. She was otherwise healthy, without chronic conditions, and she was not taking any medication. Dermoscopy showed chaotic pigmented lesion, with mainly eccentric structureless pattern eccentric black area, and central gray-brown hue. In the center of the lesion, asymmetric dark brown unequally thick lines were noted. Segmental brown radial lines were noticed at the periphery of the lesion as well as brown dots in asymmetric fashion
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To confirm the diagnosis, he underwent an excisional biopsy, which was completed by sentinel lymph node biopsy. Histology confirmed the diagnosis of malignant melanoma, with Breslow thickness of 0.6 mm,Clark level II, without a vertical growth phase, mitosis, lymphatic or vascular invasion (Fig. 24.3). Dermoscopic aspect of the lesion. A pigmented, asymmetric, with uneven borders, with multiple colours, with a diameter of about 12 mm, superficial spreading melanoma, which has grown continuously in the last 2 years was no involvement of the lymph nodes seen
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A 54-year-old female presented with an irregular hyperpigmented lesion on her right sole that quickly progressively developed for 1 year. Her lesion was itchy, painless, and about 1.5 cm in diameter with a central ulceration that produced clear discharge Before admitted, she went to private clinical and had unknown diagnosis and treatment but the lesion didn’t improve. Dermoscopy revealed a irregular asymmetric lesion with shiny white lines, polymorphous vessel hyperplasia, regression structures and blue-white veil sign
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A 54-year-old male farmer presented with a hyperpigmented macule on his right heel that developed for 3 years ago. His lesion was non-itchy, painless and increased in size rapidly and changed in color for 1 year. After that, he became hospitalized in National Hospital of Dermatology and Vereneology. Physical examination revealed not well-defined, irregular, 0.5-cm-diameter hyperpigmented plaque on the right heel. No other lesions existed anywhere, and lymph nodes were not enlarged. The rest of medical history was normal and none of his family members had similar symptoms. Dermoscopy revealed hyperpigmented lesion in the form of stone mosaic, irregular edges, little scaly surface, regular brown-to-black dots surrounding lesion with vessel hyperplasia
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A 71-year-old man presented to the dermatology outpatient clinic because of pigmented lesions on his inguinal area. In the inguinal area, 5 cm diameter, verrucous pigmented lesion was observed dermoscopic examination of this lesion revealed fissures and ridges cerebriform appearance, hairpin blood vessels, and moth-eaten border. Verrucous carcinoma and melanoma were considered and biopsy was taken. The lesion is approximately 5 cm in diameter, hyperpigmented and contains nodular areas. Fissures and ridges cerebriform appearance, hairpin blood vessels, moth-eaten border were observed in dermoscopic examination
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Dermatoscopic image of a lesion which displays asymmetry of both pattern and colour. With an abrupt border at the lower right extremity of the image (arrows) and a gradual border elsewhere, it also has marked chaos of border abruptness; melanoma invasive.
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Dermatoscopic image displaying grey colour in this in situ melanoma (arrows) contrasting with the background colour of brown – a colour invariably present in a pigmented (melanotic) melanocytic lesion.
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Dermatoscopic images of four melanomas all exhibiting chaos and the clue of grey colour (arrows). Melanoma invasive on the dorsum of the hand
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Dermatoscopic images of melanoma exhibiting chaos and the clue of grey colour (arrows).melanoma in situ on the arm
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Dermatoscopic images of melanoma exhibiting chaos and the clue of grey colour (arrows).melanoma in situ on the leg
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Dermatoscopic images of melanoma exhibiting chaos and the clue of grey colour (arrows). melanoma invasive on the leg
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Dermascopic images of melanoma exhibiting chaos and clue of blue colour.nodular melanoma on the leg
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dermascopic image of melanoma exhibiting chao and clue of blue colour.melanoma invasive arising in a dermal naevus in the groin
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Dermascopic images of melanoma exhibiting chaos and clue of blue colour.melanoma invasive on the forearm
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dermascopic images of melanoma exhibiting chaos and clue of blue colour. melanoma invasive on the abdomen.
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An eccentric structureless (light brown) area extends to the left of a structured (lines reticular) area in this dermatoscopic image of an in situ melanoma
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Dermatoscopic image of pigmented lesions each exhibiting chaos and the clue of an eccentric structureless area (arrows). Pigmented basal cell carcinoma on the leg with a pattern of angulated lines lower left and an eccentric structureless pink area upper right
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Dermatoscopic images of four pigmented lesions each exhibiting chaos and the clue of an eccentric structureless area (arrows). a melanoma in situ on the back with an eccentric structureless pink area
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Dermatoscopic images of four pigmented lesions each exhibiting chaos and the clue of an eccentric structureless area (arrows).a melanoma invasive on the back with an eccentric structureless pink area
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Dermatoscopic images of four pigmented lesions each exhibiting chaos and the clue of an eccentric structureless area (arrows). pigmented squamous cell carcinoma in situ on the back with a pattern of radial lines upper left, a structureless brown area centrally and an eccentric structureless area inferiorly (arrows).
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200
Dermatoscopic images of pigmented lesion each exhibiting chaos and the clue of peripheral black clods (arrows). Melanoma in situ on the dorsal foot
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