Abstract:
Dermatofibroma is a frequent benign tumor of easy clinical diagnosis in most cases, but that can mimic other dermatoses. Dermoscopy may help to define the diagnosis and its classical pattern is a central white area, similar to a scar, surrounded by a discrete pigment network. However, dermoscopic findings are not always typical. We describe here a case of dermatofibroma exhibiting ridges, furrows and pseudocomedos, a pattern which is typical of seborrheic keratosis, in dermoscopy.
Keywords:
Dermoscopy; Histiocytoma, benign fibrous; Keratosis, seborrheic
INTRODUCTION
Dermatofibroma is a frequent benign cutaneous neoplasm that fits the group of fibrohistiocytic skin tumors.11 Hügel H. Fibrohistiocytic skin tumors. J Dtsch Dermatol Ges. 2006;4:544-55. Most of the time the diagnosis is clinical, although it may simulate other dermatoses.11 Hügel H. Fibrohistiocytic skin tumors. J Dtsch Dermatol Ges. 2006;4:544-55.
Dermoscopy is an auxiliary method with diagnostic criteria described for several skin lesions.22 Kilinc Karaarslan I, Gencoglan G, Akalin T, Ozdemir F. Different dermoscopic faces of dermatofibromas. J Am Acad Dermatol. 2007;57:401-6. In its classical forms, the dermoscopic differentiation between seborrheic keratosis and dermatofibroma is not difficult: the former shows the pattern of ridges and furrows33 Lin J, Han S, Cui L, Song Z, Gao M, Yang G, et al. Evaluation of dermoscopic algorithm for seborrhoeic keratosis: a prospective study in 412 patients. J Eur Acad Dermatol Venereol. 2014;28:957-62. and the latter, the white scar surrounded by discrete pigment network.22 Kilinc Karaarslan I, Gencoglan G, Akalin T, Ozdemir F. Different dermoscopic faces of dermatofibromas. J Am Acad Dermatol. 2007;57:401-6.,33 Lin J, Han S, Cui L, Song Z, Gao M, Yang G, et al. Evaluation of dermoscopic algorithm for seborrhoeic keratosis: a prospective study in 412 patients. J Eur Acad Dermatol Venereol. 2014;28:957-62. Nevertheless, the findings may also be atypical and, in these cases, histopathological confirmation is required.11 Hügel H. Fibrohistiocytic skin tumors. J Dtsch Dermatol Ges. 2006;4:544-55. A case of dermatofibroma simulating seborrheic keratosis dermoscopically is here presented.
CASE REPORT
A female patient mentioned a pruritic lesion on right calf. On physical examination, a hardened tumor measuring 1.5 x 1 cm with hyperchromic surface was found (Figure 1). Clinically, the hypotheses of simple chronic lichen and dermatofibroma were suggested. The dermoscopy revealed a pattern of ridges and furrows accompanied by pseudocomedos, compatible with seborrheic keratosis (Figure 2). Histopathologic examination showed a dermal tumor composed of fusiform cells, blood vessels and foamy histiocytes. The upper dermis was not affected by cellular proliferation (Figures 3 and 4). The epidermis was acanthotic, hyperkeratotic and with keratin-filled invaginations (Figure 3).
Presence of fusocelular skin tumor sparing the upper dermis. The epidermis shows acanthosis, hyperkeratosis and kera tin-filled invaginations (asterisk) (hematoxylin-eosin, x40)
Many of the neoplastic cells present cytoplasm of foamy aspect (arrow points). Hematoxylin-eosin, x400
DISCUSSION
Typically, the dermatofibroma is an erythematous-brownish tumor of less than 1 cm and, most of the time, with a clinical diagnosis.11 Hügel H. Fibrohistiocytic skin tumors. J Dtsch Dermatol Ges. 2006;4:544-55. However, it may be confused with Spitz nevus, melanocytic composed nevus, melanoma and hemangioma.11 Hügel H. Fibrohistiocytic skin tumors. J Dtsch Dermatol Ges. 2006;4:544-55. In the described case, after macroscopic evaluation, the diagnoses of dermatofibroma and simple chronic lichen were suggested.
Even with the use of dermoscopy, diagnosis of dermatofibroma may be a challenge. Its classical dermoscopic appearance is that of a white area similar to a scar surrounded by a discrete pigment network.22 Kilinc Karaarslan I, Gencoglan G, Akalin T, Ozdemir F. Different dermoscopic faces of dermatofibromas. J Am Acad Dermatol. 2007;57:401-6. Zaballos et al., in a large series of cases, described ten dermoscopic patterns associated with this diagnosis.44 Zaballos P, Puig S, Llambrich A, Malvehy J. Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol. 2008;144:75-83. The classical pattern is the most common, present in 34% of the cases.44 Zaballos P, Puig S, Llambrich A, Malvehy J. Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol. 2008;144:75-83. Other common patterns are the discrete pigment network in all the lesion (14%) and the discrete pigment network with a white central area (9%). Nevertheless, in 6% of the cases, the dermatofibroma presents an atypical pattern44 Zaballos P, Puig S, Llambrich A, Malvehy J. Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol. 2008;144:75-83. and may simulate lentigo, blue nevus, melanoma and non-melanocytic lesions.22 Kilinc Karaarslan I, Gencoglan G, Akalin T, Ozdemir F. Different dermoscopic faces of dermatofibromas. J Am Acad Dermatol. 2007;57:401-6.
Dermoscopy of the lesion presented a pattern of ridges and furrows, classical of pigmented seborrheic keratosis22 Kilinc Karaarslan I, Gencoglan G, Akalin T, Ozdemir F. Different dermoscopic faces of dermatofibromas. J Am Acad Dermatol. 2007;57:401-6., despite its low specificity (43%)33 Lin J, Han S, Cui L, Song Z, Gao M, Yang G, et al. Evaluation of dermoscopic algorithm for seborrhoeic keratosis: a prospective study in 412 patients. J Eur Acad Dermatol Venereol. 2014;28:957-62. ; it may be observed in other dermatoses, like dermatofibroma.22 Kilinc Karaarslan I, Gencoglan G, Akalin T, Ozdemir F. Different dermoscopic faces of dermatofibromas. J Am Acad Dermatol. 2007;57:401-6. In addition, pseudocomedos could be found, which have 91% specificity for the diagnosis of seborrheic keratosis.33 Lin J, Han S, Cui L, Song Z, Gao M, Yang G, et al. Evaluation of dermoscopic algorithm for seborrhoeic keratosis: a prospective study in 412 patients. J Eur Acad Dermatol Venereol. 2014;28:957-62. Such dermoscopic findings associated with the absence of a classical dermatofibroma pattern would be sufficient to define the diagnosis of seborrheic keratosis. However, from a clinical point of view, the lesion was not compatible with this diagnosis and consequently our option was to withdraw it.
The histopathologic examination revealed a dermal tumor of fusiform cells and histiocytes, consistent with dermatofibroma.11 Hügel H. Fibrohistiocytic skin tumors. J Dtsch Dermatol Ges. 2006;4:544-55. The epidermis was acanthotic, hyperkeratotic and with keratin-filled invaginations. These findings of epidermis hyperplasia may also be found in dermatofibroma, and their presence may explain the dermoscopic aspect of ridges and furrows.11 Hügel H. Fibrohistiocytic skin tumors. J Dtsch Dermatol Ges. 2006;4:544-55.,44 Zaballos P, Puig S, Llambrich A, Malvehy J. Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol. 2008;144:75-83. This association between dermoscopic and pathologic findings is corroborated by the case herein described. Although dermoscopy is an important tool in the diagnosis of melanocytic and non-melanocytic skin lesions, the histopathologic examination is important when there is disagreement between clinical and dermoscopic diagnosis.
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Financial Support: None.
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Work carried out at the Universidade de Pernambuco (UPE) - Recife (PE), Brazil.
REFERENCES
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1Hügel H. Fibrohistiocytic skin tumors. J Dtsch Dermatol Ges. 2006;4:544-55.
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2Kilinc Karaarslan I, Gencoglan G, Akalin T, Ozdemir F. Different dermoscopic faces of dermatofibromas. J Am Acad Dermatol. 2007;57:401-6.
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3Lin J, Han S, Cui L, Song Z, Gao M, Yang G, et al. Evaluation of dermoscopic algorithm for seborrhoeic keratosis: a prospective study in 412 patients. J Eur Acad Dermatol Venereol. 2014;28:957-62.
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4Zaballos P, Puig S, Llambrich A, Malvehy J. Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol. 2008;144:75-83.
Publication Dates
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Publication in this collection
May-Jun 2016
History
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Received
14 Sept 2014 -
Accepted
25 Nov 2014