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particularly in the case of small or early lesions&#46; A correct diagnosis&#44; however&#44; is important&#44; as these entities&#44; while clinically similar&#44; differ significantly in terms of biologic behavior&#44; prognosis&#44; and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Familiarity thus with the dermoscopic features of LM-LMM and other entities in the differential diagnosis is very important for ensuring an accurate diagnosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Dermoscopic Features of Pigmented Lesions on the Face</span><p id="par0010" class="elsevierStylePara elsevierViewall">Pigmented lesions on the face have different dermoscopic features to those in other parts of the body&#46; Although the pigment network is a classic dermoscopic feature of melanocytic lesions&#44; it is very rarely found in facial lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;4</span></a> The network is formed by melanin in melanocytes or keratinocytes distributed along the long rete ridges of the epidermis&#46; The holes and lines that form this network correspond to the tips and sides of the ridges&#44; respectively&#46; Facial skin with chronic sun damage&#44; however&#44; has a different architecture&#58; it has a flat dermal-epidermal junction and may even have no rete ridges&#46; In such cases&#44; when viewed under a dermoscope&#44; pigmented keratinocytes or melanocytes are seen as diffuse brown areas interrupted by hypopigmented holes of varying width&#44; creating a &#8220;pseudonetwork&#8221;&#46; These holes correspond to hair follicle and sweat gland openings on the skin surface&#46; This pseudonetwork is observed in melanocytic and nonmelanocytic pigmented lesions on the face&#46; Diagnosis thus is based on the detection of additional criteria&#44; and while the pseudonetwork is specific to the face&#44; it does not offer any information on the lesion&#39;s histologic subtype &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;4</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In addition&#44; facial skin is fine and translucent&#44; facilitating the identification of subtle dermoscopic structures&#44; such as pigmentary incontinence and vascular structures&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Dermoscopic Features of LM-LMM</span><p id="par0020" class="elsevierStylePara elsevierViewall">The dermoscopic features of LM-LMM were first described by Schiffner et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> who analyzed 87 pigmented lesions on the face to assess the usefulness of dermoscopy in differentiating LM from solar lentigo and initial seborrheic keratosis&#46; Using univariate analysis&#44; they determined 2 specific features of LM&#58; asymmetric pigmented follicular openings and dark &#40;brown or black&#41; rhomboidal structures&#46; The multivariate logistic regression analysis showed that the combination of 4 features&#8212;asymmetric pigmented follicular openings&#44; dark rhomboidal structures&#44; slate-gray dots&#44; and slate-gray globules&#8212;had a sensitivity of 89&#37; and a specificity of 96&#37; for the diagnosis of LM&#46; The presence&#44; or absence&#44; of 1 of these features does not reliably indicate a diagnosis of LM&#44; as the features are also found in benign lesions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The authors also studied correlations with histologic findings&#44; and proposed a progression growth model for LM&#46; The first feature observed&#44; asymmetric pigmented follicular openings&#44; corresponds to the unequal descent of LM cells in individual hair follicles &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The next feature is formed by short lines produced by the tumor cells in the epidermis or the upper dermis&#44; which merge to form rhomboidal structures as the lesion advances &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The slate-gray dots and globules reflect clusters of melanophages in the upper dermis whose distribution around the follicular openings create an annular-granular pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; Finally&#44; the pigmented structures merge to completely obliterate the follicular openings&#44; indicating progression to LMM &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>D&#41;&#46; This pattern may also feature zones with whitish scar-like areas and&#47;or milky-red areas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>D&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;4&#44;6</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In a later study&#44; Stante et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> found that the Schiffner-Stolz criteria &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; could be used for the early detection of LM&#46; They described 4 cases of LM lesions measuring up to 5<span class="elsevierStyleHsp" style=""></span>mm with a homogeneous appearance that had been clinically classified as solar lentigos&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> also demonstrated the value of these criteria in a study of 51 LM-LMM lesions&#44; showing that 81&#37; had at least 1 of the 4 features&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In 2012&#44; Pralong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> described 4 additional dermoscopic criteria for LM-LMM in a study of 125 lesions&#46; Three of the criteria were present in a relatively high proportion of lesions&#58; increased density of the vascular network &#40;found in 58&#37; of lesions&#41;&#44; red rhomboidal structures &#40;40&#37;&#41;&#44; and target-like patterns &#40;41&#37;&#41;&#46; The first feature refers to the observation of a greater density of vessels in the lesion than in the surrounding skin &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#41;&#46; The red rhomboidal structures represent a vascular pattern in the form of a rhomboid around the hair follicles &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;&#46; These 2 criteria could be related to tumor neovascularization&#46; The target-like pattern describes a dark dot in the center of a hair follicle with annular hyperpigmentation &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C&#41;&#46; The fourth criterion&#44; darkening of dermoscopic examination&#44; was observed in 25&#37; of lesions&#46; This feature refers to the fact that the color seen through a dermoscope is darker than that seen in a naked-eye examination &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>D&#41;&#46; Finally&#44; the authors found at least 1 of the 4 classic dermoscopic features in 87&#37; of lesions &#40;a similar proportion to that reported by Ciudad-Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Although the simultaneous presence of 4 or more classic criteria alone has proven to accurately predict a diagnosis of LM&#44; all of the criteria have a common denominator&#58; the gray color&#46; This color is the result of melanin in the upper dermis or in the hair follicles&#46; It can be observed even before the specific dermoscopic structure has formed&#44; and for Zalaudek and her team&#44; it is the single most sensitive finding for the early detection of LM&#46; Its presence indicates the need for biopsy&#44; even in the case of small lesions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#8211;3</span></a> In 1 retrospective study of 201 cases of LM&#44; 88&#46;6&#37; of lesions displayed a gray color&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">LM-LMM can also present as an amelanotic or hypomelanotic lesion&#46; In such cases&#44; dermoscopy may reveal red to pink homogeneous areas or a pseudonetwork&#44; dotted vessels and&#47;or atypical linear vessels&#44; whitish structureless areas&#44; and chrysalis &#40;whitish streaks&#41;&#46; Traces of pigment may also be detected&#46; These findings can help to distinguish LM-LMM from other nonpigmented lesions&#44; such as actinic keratosis or superficial squamous cell carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Reflectance confocal microscopy &#40;RCM&#41; is another noninvasive technique that has been found to improve the diagnosis and management of facial LM-LMM&#46; RCM provides real-time images of the epidermis and superficial dermis with a cell-like resolution&#46; Guitera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a> created an algorithm for differentiating LM-LMM from other pigmented macules of the face with RCM&#44; and reported sensitivity and specificity rates of 85&#37; and 76&#37;&#44; respectively&#46; This method proved equally useful for diagnosing amelanotic and hypomelanotic lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a> However&#44; because of its low availability and longer processing times RCM is generally used to evaluate lesions with equivocal findings by dermoscopy rather than to provide an initial diagnostic evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a> One advantage of RCM is that it performs better than dermoscopy for guiding the selection of the biopsy site for subsequent histologic confirmation&#46; It can also help to delineate surgical margins with greater accuracy prior to surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">11&#44;12</span></a> and has even been successfully used to monitor response to nonsurgical treatment &#40;imiquimod&#44; radiation therapy&#41; in patients in whom surgery is contraindicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13&#44;14</span></a> In 1 study&#44; dermoscopy and RCM were used to detect tumor persistence in 98 LM lesions treated with imiquimod or radiation therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a> The inflammation and pigmentation secondary to these treatments make it difficult to detect recurrence&#46; Dermoscopy alone was found to have a sensitivity of 80&#37; and a specificity of just 56&#37;&#46; The criterion that was most closely correlated with treatment failure was the presence of very small brown dots with a granular but not an annular pattern&#46; These dots corresponded to pagetoid cells in the epidermis detected by RCM&#46; While asymmetric pigmented follicular openings was a specific finding &#40;present in 81&#37; of lesions&#41;&#44; it was found in just 47&#37; of recurrences&#46; RCM&#44; by contrast&#44; showed a sensitivity of 100&#37; and a specificity of 94&#37; for the detection of recurrence&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Extrafacial LM-LMM</span><p id="par0050" class="elsevierStylePara elsevierViewall">Extrafacial LM-LMM is rare&#44; and little has been published about this condition&#46; It is important to differentiate extrafacial LM-LMM from superficial spreading melanoma &#40;SSM&#41; in situ&#44; as they are 2 separate entities&#44; with specific clinical&#44; histologic&#44; and even biologic characteristics&#46; Histologically&#44; LM is characterized by a linear proliferation of atypical melanocytes&#44; with nest formation&#44; along the dermal-epidermal junction and on the walls of the hair follicles and sweat glands&#44; in association with epidermal atrophy and solar elastosis&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> The absence of pagetoid spread of melanocytes in LMM is one of the characteristics that differentiates it from SSM&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> One immunohistochemical study showed that SSM in situ cells have greater proliferative activity and higher rates of angiogenesis than LM cells&#46; These findings are consistent with the biologic behavior of these forms of melanoma&#44; as LM has a longer in situ phase than SSM&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">16</span></a> The architectural differences between facial skin and skin in other locations generated interest in whether the dermoscopic features of extrafacial LM would differ from those of facial LM&#46; Carrera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a> described a type of early-stage melanoma on the lower limbs with typical dermoscopic features of facial LM&#46; The 5 lesions had light diffuse pigmentation&#44; together with irregular pigmented follicular openings&#46; The histology study showed that the lesions were in situ melanomas with invasion of the follicles by atypical cells&#46; Lau et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> described 3 cases of extrafacial LM&#44; 2 of which had rhomboidal structures and asymmetric follicular pigmentation&#46; Although the lesions also had features of SSM &#40;irregular dots&#44; projections&#44; and an irregular pigment network&#41;&#44; the detection of rhomboidal structures and asymmetric follicular pigmentation suggested a diagnosis of extrafacial LM&#46; The presence of classic features of LM can be explained by the involvement of hair follicles in areas other than the face&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In a recent study&#44; Jaimes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a> analyzed the clinical and dermoscopic features of 186 extrafacial melanomas on chronically sun-damaged skin&#46; The lesions were distinct histologic subtypes of melanoma&#44; the most common of which was LM &#40;40&#46;9&#37;&#41;&#44; followed by SSM &#40;22&#46;6&#37;&#41;&#46; The most common structures were multiple blue-gray dots &#40;67&#46;7&#37;&#41;&#44; lines and&#47;or rhomboidal structures &#40;44&#46;1&#37;&#41;&#44; and atypical dots or globules &#40;36&#46;6&#37;&#41;&#46; Less common findings were the atypical pigment network &#40;29&#46;6&#37;&#41;&#44; asymmetric pigmented follicular openings &#40;27&#46;4&#37;&#41;&#44; brown areas without a peripheral structure &#40;24&#46;7&#37;&#41;&#44; and scar-like areas &#40;19&#46;9&#37;&#41;&#46; The authors described 3 patterns that were present in 78&#37; of cases&#58; pigmented islands &#40;reticular areas or patchy peripheral areas&#41;&#44; angulated lines &#40;a term they use to describe lines&#44; rhomboidal structures&#44; and a zig-zag pattern&#41;&#44; and a pattern consisting of brown structureless areas and blue-gray dots&#46; LM was the most common histologic subtype associated with each one of these patterns &#40;40&#37;-45&#37;&#41;&#46; Limitations of the study were that it was retrospective&#44; the evaluators already knew the diagnosis&#44; and the histological findings were not evaluated&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Our group studied 5 cases of extrafacial LM-LMM &#40;4 on the upper limbs and 1 on the trunk&#41;&#46; In all cases&#44; we observed gray dots forming an annular-granular pattern and light brown structureless areas &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5 and 6</a>A-D&#41;&#46; We observed asymmetric pigmented follicular openings in 1 case &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41; and rhomboidal structures in 2 &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>C&#44; D&#41;&#46; Our findings are similar to those of previous reports and we agree that dermoscopy could be useful for diagnosing extrafacial LM and distinguishing it from SSM&#46; This obviously has practical implications&#44; as the diagnostic and treatment approaches differ&#46; More and better-designed studies&#44; with analysis of sensitivity and specificity&#44; are needed&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical and Dermoscopic Findings in the Differential Diagnosis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The main entities in the differential diagnosis of LM are solar lentigo and flat seborrheic keratosis&#46; Schiffner and his team observed that pseudocysts&#44; yellow opaque areas&#44; and fingerprint-like structures were suggestive of solar lentigo&#44; together with the jelly sign and the moth-eaten border&#46; The presence of a pseudonetwork should not be confused with the pigment network seen in melanocytic lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>A&#41;&#46; When asymmetric pigmented follicular openings are observed on dermoscopy&#44; it is necessary to perform a biopsy or close monitoring &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Structures that are very similar to the projections of melanocytic lesions at the border of solar lentigos may be occasionally observed&#44; making it very difficult to differentiate the 2 entities&#46; Pseudofollicular openings and pseudo-milia-like cysts may be seen in thicker seborrheic keratosis lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Melanin is limited to the epidermis &#40;pigmented keratinocytes&#41; in solar lentigo&#44; and is seen as a brown color through the dermoscope&#59; the absence of gray is the most important criterion for distinguishing this condition from LM&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In pigmented actinic keratosis&#44; melanin is mainly located in the macrophages of the dermis&#44; and dermoscopy shows slate-gray dots &#40;annular-granular pattern&#41; similar to those seen in LM &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>C&#41;&#46; Any of the dermoscopic features of LM can be observed&#44; although asymmetric pigmented follicular openings tend to be absent&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;19</span></a> The presence of yellowish or white keratin plugs in the follicles is suggestive of actinic keratosis&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> Nascimiento et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> recently described a structure they called the <span class="elsevierStyleItalic">inner gray halo</span> for diagnosing pigmented actinic keratosis&#46; This structure is a gray or beige ring surrounding a hyperkeratotic follicular opening within the brown pseudonetwork &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; They analyzed this feature in 79 lesions &#40;58 pigmented actinic keratosis lesions and 21 LM lesions&#41;&#44; and found it to have a sensitivity of 91&#46;4&#37; and a specificity of 71&#46;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> Other diagnostic clues pointing to a diagnosis of pigmented actinic keratosis are the presence of multiple lesions &#40;the neighborhood sign&#41; and a rough surface&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Histologic evaluation is necessary to distinguish pigmented actinic keratosis from LM in equivocal cases&#44; although it is not always easy to determine whether the atypical pigmented cells at the basal layer are keratinocytes or melanocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The terms <span class="elsevierStyleItalic">lichenoid keratosis</span> and <span class="elsevierStyleItalic">lichen planus-like keratosis</span> refer to solar lentigo or seborrheic keratosis lesions that have undergone regression&#46; Distinguishing these lesions from LM is problematic and is only possible if some areas of the previously benign lesion remains&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a> Lichenoid keratosis that has regressed completely or almost completely is dermoscopically characterized by brown-gray dots&#44; which may merge to form globules&#44; lines&#44; or even rhomboid-like structures &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>D&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a> As these features are also seen in LM&#44; lesions of this type should always be biopsied&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">SSM can also affect the face&#46; In such cases&#44; depending on the location&#44; dermoscopy may show the pseudonetwork&#44; but this may have been destroyed in lesions with rapid horizontal growth&#46; The asymmetric pigmented follicular openings and rhomboidal structures observed in LM are not present in SSM&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Melanocytic nevus does not need to be considered in the differential diagnosis of flat&#44; pigmented lesions on chronically sun-damaged skin&#46; Nevi located on the head and neck of adults usually presents as hypopigmented cupuliform nodules &#40;Miescher-type intradermal nevi&#41;&#44; and are notably different from LM&#46; The validity of a histologic diagnosis of lentiginous nevus or junctional nevus should therefore be considered critically when the biopsy is obtained from a pigmented macule on the face of an elderly patient&#46; This diagnostic error can sometimes occur because early LM may lack significant cytologic atypia or architectural disorder&#44; making it difficult to differentiate from a lentiginous or junctional nevus&#46; Therefore&#44; familiarity with the classic clinical appearance of a facial nevus in an elderly patient will help to prevent an incorrect diagnosis of early LM&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;22</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Recognition of LM-LMM and distinction from similar lesions is challenging&#44; particularly in early stages of disease&#46; An accurate diagnosis of LM in small lesions will ensure opportune treatment and possibly improve prognosis&#46; Dermoscopy is a useful tool for the early detection of LM-LMM and should be used to evaluate all facial and extrafacial pigmented lesions&#46; A diagnosis of LM could be missed if evaluation is based only on clinical findings&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of Interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Dermoscopic Features of Pigmented Lesions on the Face"
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              "titulo" => "Dermoscopic Features of LM-LMM"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermoscopy is a noninvasive technique that improves accuracy in the diagnosis of cutaneous lesions&#46; The recognition and differential diagnosis of lentigo maligna &#40;LM&#41; and lentigo maligna melanoma &#40;LMM&#41; is challenging&#44; especially in the early stages when there are no distinctive clinical features&#46; Early diagnosis and appropriate treatment can improve prognosis&#46; Several dermoscopic features have been described for LM and LMM&#46; The following 4 criteria in combination have achieved a diagnostic sensitivity of 89&#37; and a specificity of 96&#37;&#58; asymmetric pigmented follicular openings&#44; dark rhomboidal structures&#44; slate gray dots&#44; and slate gray globules&#46; A biopsy is warranted when dermoscopic examination reveals a grayish coloring&#46; For a flat pigmented lesion acquired in adulthood&#44; a histopathological diagnosis of &#8220;atypical junctional nevus&#8221; is not to be accepted uncritically&#46; LM and LMM can also appear in sites other than the face&#44; and dermoscopy can facilitate their recognition&#46; Dermoscopy is an essential tool for physical examination&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La dermatoscopia es una t&#233;cnica no invasiva que aumenta la precisi&#243;n en el diagn&#243;stico de los tumores cut&#225;neos&#46; El reconocimiento y diagn&#243;stico diferencial del lentigo maligno &#40;LM&#41;-lentigo maligno melanoma &#40;LMM&#41; es desafiante&#44; sobre todo en etapas iniciales&#44; cuando no presenta particularidades cl&#237;nicas&#46; El diagn&#243;stico precoz posibilita un tratamiento oportuno y adecuado&#44; y podr&#237;a mejorar el pron&#243;stico&#46; Se describieron m&#250;ltiples caracter&#237;sticas dermatosc&#243;picas para el LM-LMM&#46; La combinaci&#243;n de 4 criterios otorga una sensibilidad del 89&#37; y una especificidad del 96&#37; para el diagn&#243;stico&#58; pigmentaci&#243;n asim&#233;trica de aperturas foliculares&#44; estructuras romboidales oscuras y puntos y gl&#243;bulos gris pizarra&#46; La detecci&#243;n de color gris mediante dermatoscopia amerita la realizaci&#243;n de una biopsia&#46; Ante una lesi&#243;n plana y pigmentada adquirida en la edad adulta no deber&#237;a plantearse el diagn&#243;stico hist&#243;logico de nevo juntural con atipia&#46; El LM-LMM tambi&#233;n puede aparecer fuera del rostro&#44; y la dermatoscopia ayuda a reconocerlo&#46; Es fundamental el uso de este instrumento al examinar a nuestros pacientes&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bollea-Garlatti LA&#44; Galimberti GN&#44; Galimberti RL&#46; Lentigo maligno&#46; Claves en el diagn&#243;stico dermatosc&#243;pico&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;489&#8211;497&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic features of a pigmented lesion on the face&#46; Note the highly characteristic pseudonetwork&#44; specific to this location&#46; The presence of asymmetric pigmented follicular openings suggested a diagnosis of lentigo maligna&#44; which was subsequently confirmed by histology&#46;</p>"
        ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic features of lentigo maligna&#46; A&#44; Asymmetric pigmented follicular openings &#40;black arrows&#41;&#46; B&#44; Lines starting to intersect &#40;white arrows&#41; to form rhomboidal structures &#40;black arrows&#41;&#46; C&#46; Gray dots &#40;black arrows&#41; forming a granular-annular pattern and asymmetric pigmented follicular openings &#40;white arrows&#41;&#46; D&#44; Homogeneous areas with obliteration of the follicular openings &#40;red arrow&#41; and a whitish scar-like area &#40;white arrow&#41;&#46;</p>"
        ]
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      2 => array:7 [
        "identificador" => "fig0015"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Lentigo maligna&#46; A&#44; Flat brown symmetric lesion with a diameter of 6<span class="elsevierStyleHsp" style=""></span>mm on the right cheek of an adult&#46; B&#44; Dermoscopic features&#58; asymmetric pigmented follicular openings &#40;black arrows&#41;&#46;</p>"
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      3 => array:7 [
        "identificador" => "fig0020"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Additional dermoscopic features of lentigo maligna&#46; A&#44; Increased vascular density &#40;black arrows&#41; together with asymmetric pigmented follicular openings and gray dots&#46; B&#44; Red rhomboidal structures &#40;black arrows&#41; and a gray granular-annular pattern&#46; C&#44; Target-like pattern &#40;white arrows&#41; and rhomboidal structures&#46; D&#44; Detection of darker colors in the dermoscopic examination compared with naked-eye inspection &#40;box&#41;&#46;</p>"
        ]
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      4 => array:7 [
        "identificador" => "fig0025"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Extrafacial lentigo maligna&#46; A&#44; Irregular dark brown and black lesion&#44; measuring 2<span class="elsevierStyleHsp" style=""></span>cm at its longest point&#44; in the neckline area&#46; B&#44; Dermoscopic features&#58; asymmetric pigmented follicular openings &#40;black arrows&#41;&#44; gray dots forming granular-annular pattern &#40;white arrows&#41;&#44; and brown structureless areas&#46;</p>"
        ]
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        "identificador" => "fig0030"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A-D&#44; Dermoscopic features of extrafacial lentigo maligna&#59; lesions located on the upper limbs&#46; Note the gray dots forming a granular-annular pattern in some sectors&#44; the brown structureless areas&#44; and the rhomboidal structures &#40;black arrows&#41;&#46; Lesion C is lentigo maligna melanoma&#59; note the whitish-blue veil&#46;</p>"
        ]
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        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Conditions to be considered in the differential diagnosis of lentigo maligna&#46; A&#44; Solar lentigo&#58; moth-eaten border &#40;red arrow&#41;&#44; jelly sign &#40;white arrows&#41;&#44; and pseudonetwork &#40;black arrows&#41;&#46; B&#44; Seborrheic keratosis&#58; pseudo-milia-like cysts &#40;black arrows&#41; and pseudo-follicular openings &#40;white arrows&#41;&#46; C&#44; Pigmented actinic keratosis&#58; gray dots forming a granular-annular pattern &#40;black arrows&#41;&#46; D&#44; Lichenoid keratosis&#58; gray dots and globules forming a granular-annular pattern &#40;black arrows&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Lentigo Maligna-Lentigo Maligna Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Solar Lentigo&#47;Flat Seborrheic Keratosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Pigmented Actinic Keratosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Lichenoid Keratosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymmetric pigmented follicular openings<br>Rhomboidal structures<br>Slate-gray dots<br>Slate-gray globules<br>Annular-granular pattern<br>Pseudonetwork<br><br>Red rhomboidal structures<br>Increased density of the vascular network<br>Target-like pattern<br>Darkening at dermoscopic examination<br><br>Gray color<br><br>Obliteration of follicular openings<br>Whitish scar-like areas<br>Milky-red areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yellow opaque areas<br>Jelly sign<br>Pseudo-milia-like cysts<br>Moth-eaten border<br>Fingerprint-like structures<br>Pseudonetwork<br><br>Pseudo-follicular openings<br><br>Asymmetric pigmented follicular openings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slate-gray dots<br>Annular-granular pattern<br>Inner gray halo<br>Keratin plugs<br>Pseudonetwork<br><br>Rhomboidal structures<br>Asymmetric pigmented follicular openings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Localized or diffuse gray or brown dots<br>Gray or brown globules&#44; lines&#44; and rhomboid-like structures<br>Remaining areas of seborrheic keratosis or solar lentigo with their corresponding features&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic Features of Flat Pigmented Facial Lesions&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
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Practical Dermatology
Lentigo Maligna: Keys to Dermoscopic Diagnosis
Lentigo maligno. Claves en el diagnóstico dermatoscópico
L.A. Bollea-Garlatti
Autor para correspondencia
, G.N. Galimberti, R.L. Galimberti
Centro de Cáncer de Piel y Cirugía Micrográfica de Mohs, Servicio De Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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particularly in the case of small or early lesions&#46; A correct diagnosis&#44; however&#44; is important&#44; as these entities&#44; while clinically similar&#44; differ significantly in terms of biologic behavior&#44; prognosis&#44; and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Familiarity thus with the dermoscopic features of LM-LMM and other entities in the differential diagnosis is very important for ensuring an accurate diagnosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Dermoscopic Features of Pigmented Lesions on the Face</span><p id="par0010" class="elsevierStylePara elsevierViewall">Pigmented lesions on the face have different dermoscopic features to those in other parts of the body&#46; Although the pigment network is a classic dermoscopic feature of melanocytic lesions&#44; it is very rarely found in facial lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;4</span></a> The network is formed by melanin in melanocytes or keratinocytes distributed along the long rete ridges of the epidermis&#46; The holes and lines that form this network correspond to the tips and sides of the ridges&#44; respectively&#46; Facial skin with chronic sun damage&#44; however&#44; has a different architecture&#58; it has a flat dermal-epidermal junction and may even have no rete ridges&#46; In such cases&#44; when viewed under a dermoscope&#44; pigmented keratinocytes or melanocytes are seen as diffuse brown areas interrupted by hypopigmented holes of varying width&#44; creating a &#8220;pseudonetwork&#8221;&#46; These holes correspond to hair follicle and sweat gland openings on the skin surface&#46; This pseudonetwork is observed in melanocytic and nonmelanocytic pigmented lesions on the face&#46; Diagnosis thus is based on the detection of additional criteria&#44; and while the pseudonetwork is specific to the face&#44; it does not offer any information on the lesion&#39;s histologic subtype &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;4</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In addition&#44; facial skin is fine and translucent&#44; facilitating the identification of subtle dermoscopic structures&#44; such as pigmentary incontinence and vascular structures&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Dermoscopic Features of LM-LMM</span><p id="par0020" class="elsevierStylePara elsevierViewall">The dermoscopic features of LM-LMM were first described by Schiffner et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> who analyzed 87 pigmented lesions on the face to assess the usefulness of dermoscopy in differentiating LM from solar lentigo and initial seborrheic keratosis&#46; Using univariate analysis&#44; they determined 2 specific features of LM&#58; asymmetric pigmented follicular openings and dark &#40;brown or black&#41; rhomboidal structures&#46; The multivariate logistic regression analysis showed that the combination of 4 features&#8212;asymmetric pigmented follicular openings&#44; dark rhomboidal structures&#44; slate-gray dots&#44; and slate-gray globules&#8212;had a sensitivity of 89&#37; and a specificity of 96&#37; for the diagnosis of LM&#46; The presence&#44; or absence&#44; of 1 of these features does not reliably indicate a diagnosis of LM&#44; as the features are also found in benign lesions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The authors also studied correlations with histologic findings&#44; and proposed a progression growth model for LM&#46; The first feature observed&#44; asymmetric pigmented follicular openings&#44; corresponds to the unequal descent of LM cells in individual hair follicles &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The next feature is formed by short lines produced by the tumor cells in the epidermis or the upper dermis&#44; which merge to form rhomboidal structures as the lesion advances &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The slate-gray dots and globules reflect clusters of melanophages in the upper dermis whose distribution around the follicular openings create an annular-granular pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; Finally&#44; the pigmented structures merge to completely obliterate the follicular openings&#44; indicating progression to LMM &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>D&#41;&#46; This pattern may also feature zones with whitish scar-like areas and&#47;or milky-red areas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>D&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;4&#44;6</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In a later study&#44; Stante et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> found that the Schiffner-Stolz criteria &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; could be used for the early detection of LM&#46; They described 4 cases of LM lesions measuring up to 5<span class="elsevierStyleHsp" style=""></span>mm with a homogeneous appearance that had been clinically classified as solar lentigos&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> also demonstrated the value of these criteria in a study of 51 LM-LMM lesions&#44; showing that 81&#37; had at least 1 of the 4 features&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In 2012&#44; Pralong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> described 4 additional dermoscopic criteria for LM-LMM in a study of 125 lesions&#46; Three of the criteria were present in a relatively high proportion of lesions&#58; increased density of the vascular network &#40;found in 58&#37; of lesions&#41;&#44; red rhomboidal structures &#40;40&#37;&#41;&#44; and target-like patterns &#40;41&#37;&#41;&#46; The first feature refers to the observation of a greater density of vessels in the lesion than in the surrounding skin &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#41;&#46; The red rhomboidal structures represent a vascular pattern in the form of a rhomboid around the hair follicles &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;&#46; These 2 criteria could be related to tumor neovascularization&#46; The target-like pattern describes a dark dot in the center of a hair follicle with annular hyperpigmentation &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C&#41;&#46; The fourth criterion&#44; darkening of dermoscopic examination&#44; was observed in 25&#37; of lesions&#46; This feature refers to the fact that the color seen through a dermoscope is darker than that seen in a naked-eye examination &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>D&#41;&#46; Finally&#44; the authors found at least 1 of the 4 classic dermoscopic features in 87&#37; of lesions &#40;a similar proportion to that reported by Ciudad-Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Although the simultaneous presence of 4 or more classic criteria alone has proven to accurately predict a diagnosis of LM&#44; all of the criteria have a common denominator&#58; the gray color&#46; This color is the result of melanin in the upper dermis or in the hair follicles&#46; It can be observed even before the specific dermoscopic structure has formed&#44; and for Zalaudek and her team&#44; it is the single most sensitive finding for the early detection of LM&#46; Its presence indicates the need for biopsy&#44; even in the case of small lesions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#8211;3</span></a> In 1 retrospective study of 201 cases of LM&#44; 88&#46;6&#37; of lesions displayed a gray color&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">LM-LMM can also present as an amelanotic or hypomelanotic lesion&#46; In such cases&#44; dermoscopy may reveal red to pink homogeneous areas or a pseudonetwork&#44; dotted vessels and&#47;or atypical linear vessels&#44; whitish structureless areas&#44; and chrysalis &#40;whitish streaks&#41;&#46; Traces of pigment may also be detected&#46; These findings can help to distinguish LM-LMM from other nonpigmented lesions&#44; such as actinic keratosis or superficial squamous cell carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Reflectance confocal microscopy &#40;RCM&#41; is another noninvasive technique that has been found to improve the diagnosis and management of facial LM-LMM&#46; RCM provides real-time images of the epidermis and superficial dermis with a cell-like resolution&#46; Guitera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a> created an algorithm for differentiating LM-LMM from other pigmented macules of the face with RCM&#44; and reported sensitivity and specificity rates of 85&#37; and 76&#37;&#44; respectively&#46; This method proved equally useful for diagnosing amelanotic and hypomelanotic lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a> However&#44; because of its low availability and longer processing times RCM is generally used to evaluate lesions with equivocal findings by dermoscopy rather than to provide an initial diagnostic evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a> One advantage of RCM is that it performs better than dermoscopy for guiding the selection of the biopsy site for subsequent histologic confirmation&#46; It can also help to delineate surgical margins with greater accuracy prior to surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">11&#44;12</span></a> and has even been successfully used to monitor response to nonsurgical treatment &#40;imiquimod&#44; radiation therapy&#41; in patients in whom surgery is contraindicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13&#44;14</span></a> In 1 study&#44; dermoscopy and RCM were used to detect tumor persistence in 98 LM lesions treated with imiquimod or radiation therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a> The inflammation and pigmentation secondary to these treatments make it difficult to detect recurrence&#46; Dermoscopy alone was found to have a sensitivity of 80&#37; and a specificity of just 56&#37;&#46; The criterion that was most closely correlated with treatment failure was the presence of very small brown dots with a granular but not an annular pattern&#46; These dots corresponded to pagetoid cells in the epidermis detected by RCM&#46; While asymmetric pigmented follicular openings was a specific finding &#40;present in 81&#37; of lesions&#41;&#44; it was found in just 47&#37; of recurrences&#46; RCM&#44; by contrast&#44; showed a sensitivity of 100&#37; and a specificity of 94&#37; for the detection of recurrence&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Extrafacial LM-LMM</span><p id="par0050" class="elsevierStylePara elsevierViewall">Extrafacial LM-LMM is rare&#44; and little has been published about this condition&#46; It is important to differentiate extrafacial LM-LMM from superficial spreading melanoma &#40;SSM&#41; in situ&#44; as they are 2 separate entities&#44; with specific clinical&#44; histologic&#44; and even biologic characteristics&#46; Histologically&#44; LM is characterized by a linear proliferation of atypical melanocytes&#44; with nest formation&#44; along the dermal-epidermal junction and on the walls of the hair follicles and sweat glands&#44; in association with epidermal atrophy and solar elastosis&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> The absence of pagetoid spread of melanocytes in LMM is one of the characteristics that differentiates it from SSM&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> One immunohistochemical study showed that SSM in situ cells have greater proliferative activity and higher rates of angiogenesis than LM cells&#46; These findings are consistent with the biologic behavior of these forms of melanoma&#44; as LM has a longer in situ phase than SSM&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">16</span></a> The architectural differences between facial skin and skin in other locations generated interest in whether the dermoscopic features of extrafacial LM would differ from those of facial LM&#46; Carrera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a> described a type of early-stage melanoma on the lower limbs with typical dermoscopic features of facial LM&#46; The 5 lesions had light diffuse pigmentation&#44; together with irregular pigmented follicular openings&#46; The histology study showed that the lesions were in situ melanomas with invasion of the follicles by atypical cells&#46; Lau et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> described 3 cases of extrafacial LM&#44; 2 of which had rhomboidal structures and asymmetric follicular pigmentation&#46; Although the lesions also had features of SSM &#40;irregular dots&#44; projections&#44; and an irregular pigment network&#41;&#44; the detection of rhomboidal structures and asymmetric follicular pigmentation suggested a diagnosis of extrafacial LM&#46; The presence of classic features of LM can be explained by the involvement of hair follicles in areas other than the face&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In a recent study&#44; Jaimes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a> analyzed the clinical and dermoscopic features of 186 extrafacial melanomas on chronically sun-damaged skin&#46; The lesions were distinct histologic subtypes of melanoma&#44; the most common of which was LM &#40;40&#46;9&#37;&#41;&#44; followed by SSM &#40;22&#46;6&#37;&#41;&#46; The most common structures were multiple blue-gray dots &#40;67&#46;7&#37;&#41;&#44; lines and&#47;or rhomboidal structures &#40;44&#46;1&#37;&#41;&#44; and atypical dots or globules &#40;36&#46;6&#37;&#41;&#46; Less common findings were the atypical pigment network &#40;29&#46;6&#37;&#41;&#44; asymmetric pigmented follicular openings &#40;27&#46;4&#37;&#41;&#44; brown areas without a peripheral structure &#40;24&#46;7&#37;&#41;&#44; and scar-like areas &#40;19&#46;9&#37;&#41;&#46; The authors described 3 patterns that were present in 78&#37; of cases&#58; pigmented islands &#40;reticular areas or patchy peripheral areas&#41;&#44; angulated lines &#40;a term they use to describe lines&#44; rhomboidal structures&#44; and a zig-zag pattern&#41;&#44; and a pattern consisting of brown structureless areas and blue-gray dots&#46; LM was the most common histologic subtype associated with each one of these patterns &#40;40&#37;-45&#37;&#41;&#46; Limitations of the study were that it was retrospective&#44; the evaluators already knew the diagnosis&#44; and the histological findings were not evaluated&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Our group studied 5 cases of extrafacial LM-LMM &#40;4 on the upper limbs and 1 on the trunk&#41;&#46; In all cases&#44; we observed gray dots forming an annular-granular pattern and light brown structureless areas &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5 and 6</a>A-D&#41;&#46; We observed asymmetric pigmented follicular openings in 1 case &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41; and rhomboidal structures in 2 &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>C&#44; D&#41;&#46; Our findings are similar to those of previous reports and we agree that dermoscopy could be useful for diagnosing extrafacial LM and distinguishing it from SSM&#46; This obviously has practical implications&#44; as the diagnostic and treatment approaches differ&#46; More and better-designed studies&#44; with analysis of sensitivity and specificity&#44; are needed&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical and Dermoscopic Findings in the Differential Diagnosis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The main entities in the differential diagnosis of LM are solar lentigo and flat seborrheic keratosis&#46; Schiffner and his team observed that pseudocysts&#44; yellow opaque areas&#44; and fingerprint-like structures were suggestive of solar lentigo&#44; together with the jelly sign and the moth-eaten border&#46; The presence of a pseudonetwork should not be confused with the pigment network seen in melanocytic lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>A&#41;&#46; When asymmetric pigmented follicular openings are observed on dermoscopy&#44; it is necessary to perform a biopsy or close monitoring &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Structures that are very similar to the projections of melanocytic lesions at the border of solar lentigos may be occasionally observed&#44; making it very difficult to differentiate the 2 entities&#46; Pseudofollicular openings and pseudo-milia-like cysts may be seen in thicker seborrheic keratosis lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Melanin is limited to the epidermis &#40;pigmented keratinocytes&#41; in solar lentigo&#44; and is seen as a brown color through the dermoscope&#59; the absence of gray is the most important criterion for distinguishing this condition from LM&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In pigmented actinic keratosis&#44; melanin is mainly located in the macrophages of the dermis&#44; and dermoscopy shows slate-gray dots &#40;annular-granular pattern&#41; similar to those seen in LM &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>C&#41;&#46; Any of the dermoscopic features of LM can be observed&#44; although asymmetric pigmented follicular openings tend to be absent&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;19</span></a> The presence of yellowish or white keratin plugs in the follicles is suggestive of actinic keratosis&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> Nascimiento et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> recently described a structure they called the <span class="elsevierStyleItalic">inner gray halo</span> for diagnosing pigmented actinic keratosis&#46; This structure is a gray or beige ring surrounding a hyperkeratotic follicular opening within the brown pseudonetwork &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; They analyzed this feature in 79 lesions &#40;58 pigmented actinic keratosis lesions and 21 LM lesions&#41;&#44; and found it to have a sensitivity of 91&#46;4&#37; and a specificity of 71&#46;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> Other diagnostic clues pointing to a diagnosis of pigmented actinic keratosis are the presence of multiple lesions &#40;the neighborhood sign&#41; and a rough surface&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Histologic evaluation is necessary to distinguish pigmented actinic keratosis from LM in equivocal cases&#44; although it is not always easy to determine whether the atypical pigmented cells at the basal layer are keratinocytes or melanocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The terms <span class="elsevierStyleItalic">lichenoid keratosis</span> and <span class="elsevierStyleItalic">lichen planus-like keratosis</span> refer to solar lentigo or seborrheic keratosis lesions that have undergone regression&#46; Distinguishing these lesions from LM is problematic and is only possible if some areas of the previously benign lesion remains&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a> Lichenoid keratosis that has regressed completely or almost completely is dermoscopically characterized by brown-gray dots&#44; which may merge to form globules&#44; lines&#44; or even rhomboid-like structures &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>D&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a> As these features are also seen in LM&#44; lesions of this type should always be biopsied&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">SSM can also affect the face&#46; In such cases&#44; depending on the location&#44; dermoscopy may show the pseudonetwork&#44; but this may have been destroyed in lesions with rapid horizontal growth&#46; The asymmetric pigmented follicular openings and rhomboidal structures observed in LM are not present in SSM&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Melanocytic nevus does not need to be considered in the differential diagnosis of flat&#44; pigmented lesions on chronically sun-damaged skin&#46; Nevi located on the head and neck of adults usually presents as hypopigmented cupuliform nodules &#40;Miescher-type intradermal nevi&#41;&#44; and are notably different from LM&#46; The validity of a histologic diagnosis of lentiginous nevus or junctional nevus should therefore be considered critically when the biopsy is obtained from a pigmented macule on the face of an elderly patient&#46; This diagnostic error can sometimes occur because early LM may lack significant cytologic atypia or architectural disorder&#44; making it difficult to differentiate from a lentiginous or junctional nevus&#46; Therefore&#44; familiarity with the classic clinical appearance of a facial nevus in an elderly patient will help to prevent an incorrect diagnosis of early LM&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;22</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Recognition of LM-LMM and distinction from similar lesions is challenging&#44; particularly in early stages of disease&#46; An accurate diagnosis of LM in small lesions will ensure opportune treatment and possibly improve prognosis&#46; Dermoscopy is a useful tool for the early detection of LM-LMM and should be used to evaluate all facial and extrafacial pigmented lesions&#46; A diagnosis of LM could be missed if evaluation is based only on clinical findings&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of Interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Dermoscopic Features of Pigmented Lesions on the Face"
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              "titulo" => "Dermoscopic Features of LM-LMM"
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              "identificador" => "sec0020"
              "titulo" => "Extrafacial LM-LMM"
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          "titulo" => "Clinical and Dermoscopic Findings in the Differential Diagnosis"
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            0 => "Lentigo maligna"
            1 => "Lentigo maligna melanoma"
            2 => "Dermoscopy"
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            0 => "Lentigo maligno"
            1 => "Lentigo maligno melanoma"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermoscopy is a noninvasive technique that improves accuracy in the diagnosis of cutaneous lesions&#46; The recognition and differential diagnosis of lentigo maligna &#40;LM&#41; and lentigo maligna melanoma &#40;LMM&#41; is challenging&#44; especially in the early stages when there are no distinctive clinical features&#46; Early diagnosis and appropriate treatment can improve prognosis&#46; Several dermoscopic features have been described for LM and LMM&#46; The following 4 criteria in combination have achieved a diagnostic sensitivity of 89&#37; and a specificity of 96&#37;&#58; asymmetric pigmented follicular openings&#44; dark rhomboidal structures&#44; slate gray dots&#44; and slate gray globules&#46; A biopsy is warranted when dermoscopic examination reveals a grayish coloring&#46; For a flat pigmented lesion acquired in adulthood&#44; a histopathological diagnosis of &#8220;atypical junctional nevus&#8221; is not to be accepted uncritically&#46; LM and LMM can also appear in sites other than the face&#44; and dermoscopy can facilitate their recognition&#46; Dermoscopy is an essential tool for physical examination&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La dermatoscopia es una t&#233;cnica no invasiva que aumenta la precisi&#243;n en el diagn&#243;stico de los tumores cut&#225;neos&#46; El reconocimiento y diagn&#243;stico diferencial del lentigo maligno &#40;LM&#41;-lentigo maligno melanoma &#40;LMM&#41; es desafiante&#44; sobre todo en etapas iniciales&#44; cuando no presenta particularidades cl&#237;nicas&#46; El diagn&#243;stico precoz posibilita un tratamiento oportuno y adecuado&#44; y podr&#237;a mejorar el pron&#243;stico&#46; Se describieron m&#250;ltiples caracter&#237;sticas dermatosc&#243;picas para el LM-LMM&#46; La combinaci&#243;n de 4 criterios otorga una sensibilidad del 89&#37; y una especificidad del 96&#37; para el diagn&#243;stico&#58; pigmentaci&#243;n asim&#233;trica de aperturas foliculares&#44; estructuras romboidales oscuras y puntos y gl&#243;bulos gris pizarra&#46; La detecci&#243;n de color gris mediante dermatoscopia amerita la realizaci&#243;n de una biopsia&#46; Ante una lesi&#243;n plana y pigmentada adquirida en la edad adulta no deber&#237;a plantearse el diagn&#243;stico hist&#243;logico de nevo juntural con atipia&#46; El LM-LMM tambi&#233;n puede aparecer fuera del rostro&#44; y la dermatoscopia ayuda a reconocerlo&#46; Es fundamental el uso de este instrumento al examinar a nuestros pacientes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bollea-Garlatti LA&#44; Galimberti GN&#44; Galimberti RL&#46; Lentigo maligno&#46; Claves en el diagn&#243;stico dermatosc&#243;pico&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;489&#8211;497&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic features of lentigo maligna&#46; A&#44; Asymmetric pigmented follicular openings &#40;black arrows&#41;&#46; B&#44; Lines starting to intersect &#40;white arrows&#41; to form rhomboidal structures &#40;black arrows&#41;&#46; C&#46; Gray dots &#40;black arrows&#41; forming a granular-annular pattern and asymmetric pigmented follicular openings &#40;white arrows&#41;&#46; D&#44; Homogeneous areas with obliteration of the follicular openings &#40;red arrow&#41; and a whitish scar-like area &#40;white arrow&#41;&#46;</p>"
        ]
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Lentigo maligna&#46; A&#44; Flat brown symmetric lesion with a diameter of 6<span class="elsevierStyleHsp" style=""></span>mm on the right cheek of an adult&#46; B&#44; Dermoscopic features&#58; asymmetric pigmented follicular openings &#40;black arrows&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Additional dermoscopic features of lentigo maligna&#46; A&#44; Increased vascular density &#40;black arrows&#41; together with asymmetric pigmented follicular openings and gray dots&#46; B&#44; Red rhomboidal structures &#40;black arrows&#41; and a gray granular-annular pattern&#46; C&#44; Target-like pattern &#40;white arrows&#41; and rhomboidal structures&#46; D&#44; Detection of darker colors in the dermoscopic examination compared with naked-eye inspection &#40;box&#41;&#46;</p>"
        ]
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Extrafacial lentigo maligna&#46; A&#44; Irregular dark brown and black lesion&#44; measuring 2<span class="elsevierStyleHsp" style=""></span>cm at its longest point&#44; in the neckline area&#46; B&#44; Dermoscopic features&#58; asymmetric pigmented follicular openings &#40;black arrows&#41;&#44; gray dots forming granular-annular pattern &#40;white arrows&#41;&#44; and brown structureless areas&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A-D&#44; Dermoscopic features of extrafacial lentigo maligna&#59; lesions located on the upper limbs&#46; Note the gray dots forming a granular-annular pattern in some sectors&#44; the brown structureless areas&#44; and the rhomboidal structures &#40;black arrows&#41;&#46; Lesion C is lentigo maligna melanoma&#59; note the whitish-blue veil&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Conditions to be considered in the differential diagnosis of lentigo maligna&#46; A&#44; Solar lentigo&#58; moth-eaten border &#40;red arrow&#41;&#44; jelly sign &#40;white arrows&#41;&#44; and pseudonetwork &#40;black arrows&#41;&#46; B&#44; Seborrheic keratosis&#58; pseudo-milia-like cysts &#40;black arrows&#41; and pseudo-follicular openings &#40;white arrows&#41;&#46; C&#44; Pigmented actinic keratosis&#58; gray dots forming a granular-annular pattern &#40;black arrows&#41;&#46; D&#44; Lichenoid keratosis&#58; gray dots and globules forming a granular-annular pattern &#40;black arrows&#41;&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Lentigo Maligna-Lentigo Maligna Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Solar Lentigo&#47;Flat Seborrheic Keratosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Pigmented Actinic Keratosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Lichenoid Keratosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymmetric pigmented follicular openings<br>Rhomboidal structures<br>Slate-gray dots<br>Slate-gray globules<br>Annular-granular pattern<br>Pseudonetwork<br><br>Red rhomboidal structures<br>Increased density of the vascular network<br>Target-like pattern<br>Darkening at dermoscopic examination<br><br>Gray color<br><br>Obliteration of follicular openings<br>Whitish scar-like areas<br>Milky-red areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yellow opaque areas<br>Jelly sign<br>Pseudo-milia-like cysts<br>Moth-eaten border<br>Fingerprint-like structures<br>Pseudonetwork<br><br>Pseudo-follicular openings<br><br>Asymmetric pigmented follicular openings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slate-gray dots<br>Annular-granular pattern<br>Inner gray halo<br>Keratin plugs<br>Pseudonetwork<br><br>Rhomboidal structures<br>Asymmetric pigmented follicular openings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Localized or diffuse gray or brown dots<br>Gray or brown globules&#44; lines&#44; and rhomboid-like structures<br>Remaining areas of seborrheic keratosis or solar lentigo with their corresponding features&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic Features of Flat Pigmented Facial Lesions&#46;</p>"
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      ]
    ]
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