Locum Tenens Physician,
Dakota First Nation, Portage La Prairie, Manitoba
Overview: The patient is an otherwise healthy artist from Moncton, New Brunswick who is studying native pottery production with a First Nation's band in Manitoba. She presented to our clinic with a one week history of a black macule on the left thenar eminence. The patient has a past history of nonmelanoma skin cancer and is worried that this may be a melanoma.
O/E: There is a 1 mm black macule in the above-mentioned area. Dermoscopic image suggests a vascular lesion. Note reddish black globules.
The lesions was shaved off, a small amount of H2O2 was applied and the residual hemorrhagic area was digested. The lesion disappeared!
Photographs: Clinical Image, Dermatoscopic Image before shaving. Dermatoscopic image after shave and H2O2.
Discussion: Dermoscopy established that this is a vascular lesion, a "subcorneal haematoma." Once the dermatoscopic image was appreciated, it was gently shaved off with a # 15 scalpel and it vanished. End of story. We needed no special tools in this isolated practice setting to put the patient's mind at ease. I am sure that some of our dermatoscopy experts will have more to day.
Reference:
Zalaudak I, et. al. Dermoscopy of subcorneal hematoma. Dermatol Surg Dermatol Surg. 2004 Sep;30( 9):1229-32.
Abstract
BACKGROUND:
Subcorneal hematoma is a pigmented skin lesion usually occurring on palms or soles after a trauma or sport activity. Clinically, it may exhibit overlapping features with acral melanoma or acral melanocytic nevi, leading to unnecessary excision of this otherwise harmless skin lesion.
OBJECTIVE:
The objective was to describe the dermoscopic features in a series of subcorneal hematomas.
METHODS:
Dermoscopic images of 15 subcorneal hematomas were evaluated for the presence of different colors and dermoscopic structures.
RESULTS:
In our series, a red-black hue was the most frequent color seen by dermoscopy (40% of the lesions) and a homogeneous pattern of pigmentation was the most frequent dermoscopic structure (53.3%). Remarkably, 40% of the lesions exhibited a parallel-ridge pattern that is usually found in early melanoma of palms and soles. In 46.7% of the lesions, red-black globules were additionally seen at the periphery as satellites disconnected from the lesion's body. Only two lesions showed either parallel-furrow or fibrillar pattern. A scratch test performed in four lesions, allowed complete or partial removal of the pigmentation.
CONCLUSION:
Dermoscopic features of subcorneal hematomas may be similar to those observed in acral melanocytic lesions. Nevertheless, in most cases the correct diagnosis can be facilitated by the presence of a red-black homogeneous pigmentation, often combined with satellite globules. A positive scratch test may be considered as an additional diagnostic clue.
One pattern red or purple clods is consistent with a benign vascular lesion - blood clot or haemangioma. That diagnosis should be confidently made as long as no vessels or melanin structures are seen. Vessels may be present in a haemangioma but a biopsy needs to be considered if vessels are seen to exclude a malignant vascularised lesion (like amelanotic melanoma)
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