Elevated/Pink-Clear/Red
 FIGURE 5.1 Color wheel: elevated/pink-clear/red. |
Step 1: Is the lesion flat or raised? Elevated
Step 2: What color is the lesion on clinical assessment? Pink/Clear
Step 3: What is the dermoscopic color? Red
Step 4: Is further elucidation needed to decide whether to biopsy or not? Yes
Is this a malignant or benign pattern?
Take a look at the color wheel in Figure 5.1.
Using the color wheel in Figure 5.1, cross-reference the Clinical and Dermoscopic lists:
Malignancies: Squamous cell carcinoma (SCC), basal cell carcinoma (BCC), amelanotic melanoma, Spitz nevus.
Benign: Clear cell acanthoma, lichen planus-like keratosis/irritated seborrheic keratosis, intradermal/congenital nevus, and dermatofibroma.
When considering elevated lesions, this means that amelanotic melanomas, Spitz nevi, dermatofibroma, and intradermal nevi have entered the differential. There will be similar patterns to the flat lesions, but the elevation alone brings in a new set of lesions to consider.
Again, I want to stress the importance of a good clinical history; these new lesions should be clinically suspicious as well.
Benign Lesions
Intradermal Nevi (IN)/Congenital Nevi (CN)
Pearls
Elevated/Pink-Clear/Red
Skin-colored papules that patients will have had for a long time; sometimes flat lesions can become neurotized or three dimensional, and patients may believe that they are new.
When IN or CNs are on the face, they can become irritated, making them clinically difficult to differentiate from BCCs.
Wobble: When moved, these lesions wobble back and forth.
Step 4 Pattern: You may see some benign patterns such as coma-like vessels, faint pigmentation, or milia-like cysts. However, more importantly, you’ll see a lack of the malignant features we covered in our patterns chapter of melanoma, SCC, or BCC.
Bottom line: Benign, biopsy is not necessary.
Examples
Figure 5.2 shows the classic clinical (Figure 5.2A, B) and dermoscopic (Figure 5.2C) findings of an IN on the neck. We can clearly see the elevated, pink/fleshy-colored, “wobbly” looking lesion clinically. Dermoscopically, we see red comma-like vessels with no malignant patterns on dermoscopy. Diagnosis: Intradermal nevi (IN)/congenital nevi (CN).
Bottom line: Benign, biopsy not necessary.
Figure 5.3 shows another example of the clinical (Figure 5.3A, B) and dermoscopic (Figure 5.3C) presentation of an IN. This elevated, pink/fleshy, protruding, wobbly lesion on the trunk shows no signs of malignancy, either clinically or dermoscopically. Again, we can see red comma-like vessels on dermoscopy. Diagnosis: Intradermal nevi (IN)/congenital nevi (CN).
Bottom line: Benign, biopsy not necessary.
Figure 5.4 clearly depicts IN. They are elevated, fleshy/pink wobbly lesions clinically, with red comma-like vessels dermoscopically. Diagnosis: Intradermal nevi (IN)/congenital nevi (CN).
Bottom line: Benign, biopsy not necessary.
 FIGURE 5.2 Clinically elevated lesions that are pink or skin-colored with a vascular/red dermoscopic pattern. A and B show a clinical example of an intradermal nevus. C: Dermoscopically, comma-like vessels are seen. Intradermal nevi wobble when moved back and forth with a contact dermatoscope. |
Figure 5.5 shows clinically elevated, pink/skin-colored lesions with a red vascular dermoscopic pattern. Based on the clinical picture and dermoscopic finding, we are assured that this is an intradermal lesion with no malignant features, but rather, benign commalike vessels on dermoscopy. Sometimes, you may see milia-like cysts and faint pigmentation, which are other benign features that we see here. Diagnosis: Intradermal nevi (IN)/congenital nevi (CN).
Bottom line: Benign, biopsy not necessary.
 FIGURE 5.3 Clinically elevated lesions that are pink or skin-colored with a vascular/red dermoscopic pattern. A and B show a clinical example of an intradermal nevus. C: Dermoscopically, comma-like vessels are seen. Intradermal nevi wobble when moved back and forth with a contact dermatoscope. |
 FIGURE 5.4 A-C: Intradermal nevi wobble when moved back and forth and have comma-like vessels. Sometimes you can see faint pigmentation. |
 FIGURE 5.5 Clinically elevated lesions that are pink or skin-colored with a vascular/red dermoscopic pattern. A and B show a clinical example of a congenital nevus. C: The dermoscopic image shows comma-like vessels. Sometimes you see milia-like cysts and faint pigmentation. |
Dermatofibroma
Pearls
Elevated/Pink-Clear/Red
These raised and often palpable nodules can dimple on clinical exam.
Typically smooth and well circumscribed.
On dermoscopy, a faint pseudonetwork or fishnet-like network at the periphery of the lesion.
Sometimes, you can see diffuse dots, which you may recall can be seen in flat superficial squamous cells, but remember that dermatofibromas are elevated and palpable, whereas superficial SCCs are not.
These occur in an older patient population as a scar-like reaction, so you can sometimes see a scar-like pattern at the center of these lesions.
These can also show nonspecific inflammation on dermoscopy, but because they are elevated and firm/palpable, they are distinguished from malignant lesions.
Step 4 Pattern: In some, you may see a scar-like pattern in the center with some faint pigmentation or a faint pseudonetwork at the periphery. Again, diffuse dots in these lesions are common and are not indicative of malignancy because of the elevation of the lesion. There is a lack of the malignant features we covered in our patterns chapter of melanoma, SCC, or BCC.
Bottom line: Benign, biopsy is not necessary.
Examples
In Figure 5.6 we see a clinical and dermoscopic example of a dermatofibroma. We can see in parts Figure 5.6A and B that the lesion is elevated and pink; additionally, it will be firmly palpable. In part Figure 5.6C, we can see a nonspecific red vascular pattern/inflammation with a scar-like pattern at the center and faint pigmentation at the periphery of the lesion. Diagnosis: Dermatofibroma.
Bottom line: Benign, biopsy not necessary.
Figure 5.7 is another example of a clinically elevated, pink, and firmly palpable lesion. Dermoscopically, we see the nonspecific red inflammation, but again, we distinguish this from malignancy because this lesion is clinically elevated. Diagnosis: Dermatofibroma.
Bottom line: Benign, biopsy not necessary.
 FIGURE 5.6 Clinically elevated lesions that are pink or skin-colored with a vascular/red dermoscopic pattern. A,B: Clinical examples of dermatofibromas. C: This dermoscopic image shows a nonspecific vascular pattern. Dermatofibromas are palpable and have a scar-like center, with a faint pigment or pseudonetwork at the periphery. |
In Figure 5.8, we see an example of a dermatofibroma on the foot. Again, we see a clinically raised, pink lesion that will be firmly palpable. Dermoscopically, you can see faint pigmentation and a red diffuse dot pattern. This cannot be confused with flatter lesions with diffuse dots such as SCC or psoriasis because this lesion is elevated and palpable. Diagnosis: Dermatofibroma.
Bottom line: Benign, biopsy not necessary.
 FIGURE 5.7 Clinically elevated lesions that are pink or skin-colored with a vascular/red dermoscopic pattern. A,B: Clinical examples of dermatofibromas. C: This dermoscopic image shows a nonspecific vascular pattern. Dermatofibromas are palpable.
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