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Detection of early basal cell carcinoma with dermoscopy in a patient with psoriasis

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Detection of early basal cell carcinoma with dermoscopy in a patient with psoriasis
Tracey N Liebman BA, Steven Q Wang MD
Dermatology Online Journal 17 (2): 12

Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, New York

Abstract

A 49-year-old man with a history of basal cell carcinoma and psoriasis presented for routine skin exam and psoriasis management. He had multiple erythematous, scaly patches and plaques, originally diagnosed as psoriasis. Noticeably, one erythematous patch had a focal erosion. Dermoscopy revealed arborizing vessels, an erosion, pink structureless areas, and short, fine telangiectasias (SFTs), suggestive of superficial basal cell carcinoma (sBCC). Dermoscopy of all other lesions was consistent with psoriasis, exhibiting dotted vessels on a faint erythematous background. In conclusion, sBCCs may be overlooked in patients with multiple psoriatic plaques. In this case, the lesions were all initially presumed to be psoriasis. After detecting an erosion, the clinician was prompted to inspect further with dermoscopy and biopsy. Suspicion of sBCC was confirmed after visualization of dermoscopic structures consistent with sBCC. We highlight this case to encourage the use of dermoscopy in these patients for prompt diagnosis of BCCs.



Introduction

A 49-year-old man with a history of basal cell carcinoma (BCC) and psoriasis presented for routine annual skin exam and management of psoriasis. Upon clinical examination, the patient had multiple erythematous, scaly patches and plaques located on the back, abdomen, arms, and legs, which were suggestive of psoriasis (Figure 1). Noticeably, one smaller erythematous patch on the right elbow showed a focal erosion (<1 mm) (Figure 2). Dermoscopy of this lesion revealed arborizing vessels, an erosion, pink structureless areas, and short, fine telangiectasias (SFTs) (Figure 3). Collectively, these structures were indicative of superficial basal cell carcinoma (sBCC). This lesion was biopsied, and pathology confirmed the diagnosis of sBCC. The other lesions were also examined using dermoscopy; most of these lesions were consistent with psoriasis and exhibited red dotted vessels in the setting of a faint erythematous background (Figure 4).


Figure 1Figure 2
Figure 1. Clinical image of multiple erythematous, scaly plaques and patches on abdomen and right arm. The clinical diagnosis of these lesions initially was psoriasis.

Figure 2. Clinical image of multiple erythematous, scaly plaques and patches on abdomen and right arm. A small erosion is present within the lesion on the right elbow (arrow).

Figure 3Figure 4
Figure 3. Dermoscopy of the lesion on the right elbow, which exhibits an erosion (thin black arrow), arborizing vessels (dotted black arrow), short fine telangiectasias (thick black arrow), and pink structureless areas (asterisk). The dermoscopic appearance was suggestive of sBCC, which was subsequently confirmed on histopathology.

Figure 4. Dermoscopic image of psoriasis on the patient’s back; red dotted vessels arranged in a regular distribution (in dotted circle) with a light red background. The dermoscopic appearance is consistent with psoriasis.

Comment

Dermoscopy has become an indispensible tool to assist in the diagnosis of a plethora of dermatologic conditions. Initially, dermoscopy was extensively used for the diagnosis of melanocytic lesions, but its utility has extended into non-melanocytic tumors and other types of dermatologic conditions. Classic dermoscopic structures of sBCCs include pink or white semi-translucent or opaque structureless areas, multiple small surface erosions, and SFTs with a haphazard distribution [1, 2]. Short, fine telangiectasias (SFTs), also known as microarborizing vessels, have minimal branching [1]; they are short in length and less than 1 millimeter in width [2]. Other findings that can also be observed in sBCCs include leaf-like areas, spoke wheel areas, concentric structures, blue gray globules, brown dots and globules, and large blue-gray ovoid nests [1, 3]. Large diameter arborizing (tree-like) vessels are rarely seen in sBCCs [1]. Superficial BCCs can present clinically as scaly erythematous papules, patches, or plaques. Additionally, a small amount of visible pigment or an erosion may be present [4, 5]. Although sBCCs are often seen on the trunk, they can also be observed on the extremities, as was observed in this case [6, 7]. Typical dermoscopic features of psoriasis, in contrast, consist of red dotted vessels homogenously distributed on a light red background that was revealed in each of the patient’s psoriatic lesions [8]. Clinically, psoriasis often manifests as well-defined, erythematous papules or plaques with silvery scale, especially on the extensor surfaces, as was reflected in this patient’s psoriatic lesions on the trunk and extremities [9, 10].

In summary, psoriasis is a common condition that is readily diagnosed with visual inspection and tactile palpation. However, there are scenarios in which sBCC or even squamous cell carcinoma may be overlooked by clinicians, especially in patients with multiple psoriatic plaques. The occurrence of skin cancer in psoriatic patients is not uncommon, especially in patients who have received natural sunlight and phototherapy to treat the psoriasis. Hence, it may be helpful to include a dermoscopic exam in patients with psoriasis. Close inspection may be especially warranted for those lesions with focal erosions or ulcerations. Based on the dermoscopy pattern, a clear distinction between sBCC and psoriasis can be established, as demonstrated by this case.

References

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