PRACTICAL DERMOSCOPY
Unexpected Diagnosis of Basal Cell Carcinoma
Diagnóstico «por los pelos»
R. Pigem
, A. Gomes, A. Bennàssar, C. Carrera
Corresponding author
Unitat de Melanoma, Servicio de Dermatología, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Pigem, A. Gomes, A. Bennàssar, C. Carrera" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Pigem" "email" => array:1 [ 0 => "RPIGEM@clinic.ub.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Gomes" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Bennàssar" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Carrera" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unitat de Melanoma, Servicio de Dermatología, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diagnóstico «por los pelos»" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 750 "Ancho" => 563 "Tamanyo" => 217146 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Histologic micrograph showing nests and cords of basaloid cells infiltrating the dermis and a hair follicle cut lengthwise (hematoxylin-eosin ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 28 year old man with no significant past medical history and no androgenetic alopecia consulted for a scalp lesion that had been identified by chance following a haircut (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Clinically, the lesion was a poorly defined, completely asymptomatic and lightly pigmented plaque.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Comment</span><p id="par0010" class="elsevierStylePara elsevierViewall">The first diagnosis considered was basal cell carcinoma, although given the patient's age and the site of the lesion a melanocytic lesion with fibrotic features was also a possibility. Dermoscopy revealed a multicolored lesion with poorly defined borders and a bright white spot that corresponded to a milia-like cyst. The dermoscopic findings did not fulfill any of the criteria for a melanocytic lesion, although a few isolated gray-brown globular structures were observed. A single blue-gray rhomboid-ovoid structure was visible in the center of the lesion. While follicular openings were preserved, dark brown granular structures were seen in a perifollicular distribution (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In consultation with the patient, it was decided to conduct an additional investigation with in vivo reflectance confocal microscopy. This revealed refractile nests of nucleated cells with peripheral palisading and dark cleft-like spaces (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the dermoscopic and confocal microscopy findings consistent with basal cell carcinoma, a complete excision of the lesion was performed and the diagnosis of infiltrative basal cell carcinoma was confirmed histologically (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The scalp, besides being an anatomical area that is normally hidden, has particular clinical, dermoscopic, and histologic characteristics because it is highly vascularized and has a high density of pilosebaceous units. Consequently skin lesions on the scalp, in addition to going unnoticed during physical examination, also pose a diagnostic challenge.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Between 13% and 33% of people have a nevus or nevi on the scalp. Of these, up to 5% are considered atypical, a type found more often in young people.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the present case, since the lesion, had irregular borders and was asymmetric, pigmented, multicolored, and measured more than 6mm in diameter, the differential diagnosis included fibrosing blue nevus and melanocytic nevus with atypical features and fibrosis. Moreover, no information was available on the time elapsed since onset. The brown-gray globular structures revealed by dermoscopy could be confused with the actual globules of a melanocytic lesion. We also considered the possibility that the lesion might be an adnexal tumor—such as a basaloid follicular hamartoma, a trichoepithelioma, or a trichoblastoma—given the presence of a milia-like cyst and perifollicular pigmented structures. The typical dermoscopic features reported for basaloid follicular hamartoma include a globular and cobblestone pattern with white, pink, and deep gray areas, horny plugs, and milia-like cysts.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This case highlights the importance of a detailed exploration of the scalp since even a young patient with no risk factors may develop an infiltrative basal cell carcinoma. This histologic subtype rarely presents as a hyperpigmented lesion.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> Finally, in vivo confocal microscopy allowed us to confirm the diagnosis of basal cell carcinoma suspected on the basis of dermoscopic findings, and to perform surgical excision of the lesion immediately.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Presentation" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Comment" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pigem R, Gomes A, Bennàssar A, Carrera C. Diagnóstico «por los pelos». Actas Dermosifiliogr. 2015;106:425–426.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 522 "Ancho" => 696 "Tamanyo" => 115986 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image of the lesion, an asymptomatic brown macule with poorly defined edges located on the apex of the scalp.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 522 "Ancho" => 696 "Tamanyo" => 61898 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic image showing the asymmetric pattern of structures and irregular edges. The lesion is multicolored, with light and dark brown, blue-gray, and red areas as well as a bright white spot corresponding to a milia-like cyst. Oval structures can be discerned. While the vascular structures are not clearly apparent, fine vessels giving rise to diffuse erythema can be seen.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 577 "Ancho" => 770 "Tamanyo" => 118420 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Image obtained using reflectance confocal microscopy showing hyperrefractile groups of cells arranged in nests.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 750 "Ancho" => 563 "Tamanyo" => 217146 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Histologic micrograph showing nests and cords of basaloid cells infiltrating the dermis and a hair follicle cut lengthwise (hematoxylin-eosin ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proposal for clinical-dermoscopic classification of scalp naevi" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Zalaudek" 1 => "K. Schmid" 2 => "A. Niederkorn" 3 => "R. Fink-Puches" 4 => "E. Richting" 5 => "I. Wolf" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.12722" "Revista" => array:7 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2014" "volumen" => "170" "paginaInicial" => "1065" "paginaFinal" => "1072" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24641327" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028212021231" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence and distribution of melanocytic naevi on the scalp: A prospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "V. De Giorgi" 1 => "S. Sestini" 2 => "M. Grazzini" 3 => "A. Janowska" 4 => "V. Boddi" 5 => "T. 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Casado" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ad.2010.07.009" "Revista" => array:7 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2011" "volumen" => "102" "paginaInicial" => "233" "paginaFinal" => "235" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21392727" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1472648310004608" "estado" => "S300" "issn" => "14726483" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classifyng distinct basal cell carcinoma subtype by means of dermatoscopy and reflectance confocal microscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Longo" 1 => "A. Lallas" 2 => "A. Kyrgidis" 3 => "H. Rabinovitz" 4 => "E. Moscarella" 5 => "S. Ciardo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2014.04.067" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2014" "volumen" => "71" "paginaInicial" => "716" "paginaFinal" => "724" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24928707" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010600000005/v1_201506041458/S1578219015001018/v1_201506041458/en/main.assets" "Apartado" => array:4 [ "identificador" => "19289" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Practical Dermoscopy" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010600000005/v1_201506041458/S1578219015001018/v1_201506041458/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015001018?idApp=UINPBA000044" ]
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| 2023 January | 62 | 30 | 92 |
| 2022 December | 77 | 38 | 115 |
| 2022 November | 39 | 26 | 65 |
| 2022 October | 32 | 18 | 50 |
| 2022 September | 39 | 35 | 74 |
| 2022 August | 27 | 32 | 59 |
| 2022 July | 23 | 25 | 48 |
| 2022 June | 23 | 22 | 45 |
| 2022 May | 48 | 39 | 87 |
| 2022 April | 52 | 35 | 87 |
| 2022 March | 49 | 44 | 93 |
| 2022 February | 30 | 24 | 54 |
| 2022 January | 28 | 39 | 67 |
| 2021 December | 27 | 34 | 61 |
| 2021 November | 33 | 37 | 70 |
| 2021 October | 30 | 44 | 74 |
| 2021 September | 23 | 35 | 58 |
| 2021 August | 24 | 38 | 62 |
| 2021 July | 26 | 19 | 45 |
| 2021 June | 21 | 33 | 54 |
| 2021 May | 45 | 25 | 70 |
| 2021 April | 88 | 82 | 170 |
| 2021 March | 56 | 15 | 71 |
| 2021 February | 48 | 18 | 66 |
| 2021 January | 31 | 18 | 49 |
| 2020 December | 30 | 16 | 46 |
| 2020 November | 18 | 17 | 35 |
| 2020 October | 15 | 10 | 25 |
| 2020 September | 26 | 12 | 38 |
| 2020 August | 22 | 20 | 42 |
| 2020 July | 28 | 11 | 39 |
| 2020 June | 45 | 26 | 71 |
| 2020 May | 26 | 24 | 50 |
| 2020 April | 30 | 24 | 54 |
| 2020 March | 30 | 18 | 48 |
| 2020 February | 4 | 4 | 8 |
| 2020 January | 4 | 5 | 9 |
| 2019 December | 8 | 3 | 11 |
| 2019 November | 4 | 0 | 4 |
| 2019 October | 1 | 0 | 1 |
| 2019 September | 9 | 1 | 10 |
| 2019 August | 4 | 3 | 7 |
| 2019 July | 3 | 1 | 4 |
| 2019 June | 5 | 16 | 21 |
| 2019 May | 7 | 30 | 37 |
| 2019 April | 15 | 14 | 29 |
| 2019 March | 4 | 6 | 10 |
| 2019 February | 6 | 4 | 10 |
| 2019 January | 6 | 0 | 6 |
| 2018 December | 4 | 4 | 8 |
| 2018 November | 5 | 0 | 5 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 6 | 0 | 6 |
| 2018 March | 1 | 0 | 1 |
| 2018 February | 49 | 5 | 54 |
| 2018 January | 34 | 4 | 38 |
| 2017 December | 63 | 7 | 70 |
| 2017 November | 29 | 3 | 32 |
| 2017 October | 28 | 7 | 35 |
| 2017 September | 30 | 12 | 42 |
| 2017 August | 39 | 6 | 45 |
| 2017 July | 30 | 7 | 37 |
| 2017 June | 43 | 7 | 50 |
| 2017 May | 41 | 6 | 47 |
| 2017 April | 49 | 11 | 60 |
| 2017 March | 44 | 5 | 49 |
| 2017 February | 23 | 3 | 26 |
| 2017 January | 13 | 4 | 17 |
| 2016 December | 35 | 6 | 41 |
| 2016 November | 45 | 8 | 53 |
| 2016 October | 31 | 5 | 36 |
| 2016 September | 0 | 3 | 3 |
| 2016 August | 0 | 1 | 1 |
| 2016 July | 8 | 1 | 9 |
| 2016 June | 14 | 2 | 16 |
| 2016 May | 16 | 3 | 19 |
| 2016 April | 6 | 13 | 19 |
| 2016 March | 5 | 2 | 7 |
| 2016 February | 11 | 1 | 12 |
| 2016 January | 5 | 0 | 5 |
| 2015 December | 11 | 2 | 13 |
| 2015 October | 0 | 1 | 1 |
| 2015 August | 0 | 3 | 3 |
| 2015 July | 18 | 3 | 21 |
| 2015 June | 16 | 5 | 21 |
Show all
