PRACTICAL DERMOSCOPY
Unexpected Diagnosis of Basal Cell Carcinoma
Diagnóstico «por los pelos»
R. Pigem
, A. Gomes, A. Bennàssar, C. Carrera
Autor para correspondencia
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. Lotti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2009.09486.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2010" "volumen" => "162" "paginaInicial" => "345" "paginaFinal" => "349" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19886886" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Simultaneous presentation of localized basaloid folicular hamartoma and epithelioid blue nevus in a 44-year-old patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Mauleón" 1 => "M. Valdivielso" 2 => "E. Chavarría" 3 => "J.M. Hernanz" 4 => "I. 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 Mayo | 62 | 25 | 87 |
| 2023 Abril | 60 | 15 | 75 |
| 2023 Marzo | 58 | 19 | 77 |
| 2023 Febrero | 61 | 23 | 84 |
| 2023 Enero | 62 | 30 | 92 |
| 2022 Diciembre | 77 | 38 | 115 |
| 2022 Noviembre | 39 | 26 | 65 |
| 2022 Octubre | 32 | 18 | 50 |
| 2022 Septiembre | 39 | 35 | 74 |
| 2022 Agosto | 27 | 32 | 59 |
| 2022 Julio | 23 | 25 | 48 |
| 2022 Junio | 23 | 22 | 45 |
| 2022 Mayo | 48 | 39 | 87 |
| 2022 Abril | 52 | 35 | 87 |
| 2022 Marzo | 49 | 44 | 93 |
| 2022 Febrero | 30 | 24 | 54 |
| 2022 Enero | 28 | 39 | 67 |
| 2021 Diciembre | 27 | 34 | 61 |
| 2021 Noviembre | 33 | 37 | 70 |
| 2021 Octubre | 30 | 44 | 74 |
| 2021 Septiembre | 23 | 35 | 58 |
| 2021 Agosto | 24 | 38 | 62 |
| 2021 Julio | 26 | 19 | 45 |
| 2021 Junio | 21 | 33 | 54 |
| 2021 Mayo | 45 | 25 | 70 |
| 2021 Abril | 88 | 82 | 170 |
| 2021 Marzo | 56 | 15 | 71 |
| 2021 Febrero | 48 | 18 | 66 |
| 2021 Enero | 31 | 18 | 49 |
| 2020 Diciembre | 30 | 16 | 46 |
| 2020 Noviembre | 18 | 17 | 35 |
| 2020 Octubre | 15 | 10 | 25 |
| 2020 Septiembre | 26 | 12 | 38 |
| 2020 Agosto | 22 | 20 | 42 |
| 2020 Julio | 28 | 11 | 39 |
| 2020 Junio | 45 | 26 | 71 |
| 2020 Mayo | 26 | 24 | 50 |
| 2020 Abril | 30 | 24 | 54 |
| 2020 Marzo | 30 | 18 | 48 |
| 2020 Febrero | 4 | 4 | 8 |
| 2020 Enero | 4 | 5 | 9 |
| 2019 Diciembre | 8 | 3 | 11 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 1 | 0 | 1 |
| 2019 Septiembre | 9 | 1 | 10 |
| 2019 Agosto | 4 | 3 | 7 |
| 2019 Julio | 3 | 1 | 4 |
| 2019 Junio | 5 | 16 | 21 |
| 2019 Mayo | 7 | 30 | 37 |
| 2019 Abril | 15 | 14 | 29 |
| 2019 Marzo | 4 | 6 | 10 |
| 2019 Febrero | 6 | 4 | 10 |
| 2019 Enero | 6 | 0 | 6 |
| 2018 Diciembre | 4 | 4 | 8 |
| 2018 Noviembre | 5 | 0 | 5 |
| 2018 Octubre | 6 | 0 | 6 |
| 2018 Septiembre | 6 | 0 | 6 |
| 2018 Marzo | 1 | 0 | 1 |
| 2018 Febrero | 49 | 5 | 54 |
| 2018 Enero | 34 | 4 | 38 |
| 2017 Diciembre | 63 | 7 | 70 |
| 2017 Noviembre | 29 | 3 | 32 |
| 2017 Octubre | 28 | 7 | 35 |
| 2017 Septiembre | 30 | 12 | 42 |
| 2017 Agosto | 39 | 6 | 45 |
| 2017 Julio | 30 | 7 | 37 |
| 2017 Junio | 43 | 7 | 50 |
| 2017 Mayo | 41 | 6 | 47 |
| 2017 Abril | 49 | 11 | 60 |
| 2017 Marzo | 44 | 5 | 49 |
| 2017 Febrero | 23 | 3 | 26 |
| 2017 Enero | 13 | 4 | 17 |
| 2016 Diciembre | 35 | 6 | 41 |
| 2016 Noviembre | 45 | 8 | 53 |
| 2016 Octubre | 31 | 5 | 36 |
| 2016 Septiembre | 0 | 3 | 3 |
| 2016 Agosto | 0 | 1 | 1 |
| 2016 Julio | 8 | 1 | 9 |
| 2016 Junio | 14 | 2 | 16 |
| 2016 Mayo | 16 | 3 | 19 |
| 2016 Abril | 6 | 13 | 19 |
| 2016 Marzo | 5 | 2 | 7 |
| 2016 Febrero | 11 | 1 | 12 |
| 2016 Enero | 5 | 0 | 5 |
| 2015 Diciembre | 11 | 2 | 13 |
| 2015 Octubre | 0 | 1 | 1 |
| 2015 Agosto | 0 | 3 | 3 |
| 2015 Julio | 18 | 3 | 21 |
| 2015 Junio | 16 | 5 | 21 |
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