Elevated/Pale Brown/Multicolored

FIGURE 11.1 Color wheel: elevated/pale brown/multicolored.

Take a look at the color wheel in Figure 11.1.

What’s missing on the differential? Malignant lesions!

If you evaluate a lesion and determine that it is a clinically elevated, pale brown and dermoscopically multicolored lesion, you are likely home free. You will not need to biopsy these lesions, with one important exception.

Our differential includes only benign entities, congenital and intradermal nevi, as well as irritated seborrheic keratosis or lichen planus-like keratosis. There are no malignancies on our list. Occasionally, actinic keratosis may grow within an irritated seborrheic keratosis or LPLK, and this would need to be biopsied. Unfortunately, there is no reliable way to determine malignant growth inside a benign seborrheic keratosis, so if the lesion is clinically inflamed or irritated, it should be biopsied.

Let’s look at some examples in order to show when we don’t need to biopsy these lesions and can move on in the examination of our patients. Pattern evaluation will not be necessary for these lesions. When dealing with inflamed lesions, we need to take a slightly different approach. When the inflammation is great, it obscures the benign features of the lesion, and biopsy is often necessary to rule out malignancy. If the inflammation is minimal and benign features—ridges, milia-like cysts—are more prominent, observation, instead of biopsy, is warranted.

Examples

Figure 11.2 shows a clinically elevated, pale brown lesion (Figure 11.2A, B) with a dermoscopically multicolored (brown + other = gray, pink, or yellow) pattern. This is an example of a congenital nevus, and pattern assessment is not necessary. However, if you remember from
Chapter 1, we may see comma-like vessels and a globular dot pattern. Additionally, this lesion wobbles when in contact with the dermatoscope (Figure 11.3A, B). Diagnosis: Congenital nevus.

FIGURE 11.2 Clinically elevated lesions that are pale brown, with a multicolored (brown + other = gray, pink, and/or yellow) dermoscopic pattern. Review these clinical and dermoscopic examples of a congenital nevus. A,B: Clinical examples. C: The dermoscopic example shows a dot/globular pattern. You can see comma-like vessels and dark dots on the network. Additionally, this lesion wobbles when a contact scope is applied to it.

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