case_images: PMC2945651_01
case_images: Forearm of a 54-year-old man. A hard blue asymptomatic nodule (a). Dermoscopically, the lesion showed a purple-bluish hue (white arrow), with a whitish veil and chrysalis structures (black arrow) ((b) 30x magnification). The confocal images show thick hyporeflective fibers of collagen in the dermis (yellow asterisks). Among these, hyperreflective dotted particles (white arrow heads) and several large multinucleated cells, plump and refractile, were seen (yellow arrow) ((c), (d) details 500 x 500 mum). Histology revealed a fibrous hystiocytoma, with spindled fibro-hystiocytes, blood extravasation (black arrow) and numerous siderophages ((e) HH 20x magnification): in particular, plump bright multinucleated cells were identified as haemosiderophages, clearly visible in the upper portion of the dermis (yellow arrow). The flattening of the dermal-epidermal junction is highlighted by a red asterisk.
case_images: DRP2010-168248.001.jpg
case_images: PMC2945651_01_DRP2010-168248.001.jpg
case_images: fig1
case_images: The history was of a slowly growing lesion, not painful, with a hard-elastic consistency (Figure 1(a)). In the center of the lesion, some intensely white structures with well-defined borders were present, whereas at the periphery chrysalis structures were observed, corresponding to shiny, bright white, orthogonal linear streaks (Figure 1(b)). A flattening of the dermal-epidermal junction resulted in the absence of papillae (Figure 1(c)). In the superficial dermis, thick hyporeflective fibers of collagen were visible, mixed with small hyperreflective dotted particles, corresponding to leukocytic inflammatory cells (Figure 1(c)). These large cells were variable in shape and brightness and slightly blurred. (Figure 1(d)). Very high correspondence between confocal and histologic images was observed (Figure 1(e)); in particular, plump bright multinucleated cells were identified as haemosiderophages, clearly visible in the upper portion of the dermis.
case_images: PMC2945651_02
case_images: Back of a 58-year-old man. This grayish nodule of unknown history was warty and itchy (a). Dermoscopy showed a whitish veil all over the lesion (white arrow), comedo-like openings (yellow circles) and a hyperpigmented area at the periphery (black arrow) ((b) 20x magnification). The confocal examination shows the lack of the melanocytic component, bright papillary structures (blue arrows) with bulbous projections of epidermal cells, characterized by a blurred appearance (yellow arrows), due to superficial hyperkeratosis ((c), (d) details 500 x 500 mum). Histology shows a seborrheic keratosis ((e) HH 10x magnification); along the horizontal section (white interrupted line), epithelial cell proliferation corresponds to bulbous projections (yellow arrow) circumscribing dermal areas corresponding to papillae (blue arrow).
case_images: DRP2010-168248.002.jpg
case_images: PMC2945651_02_DRP2010-168248.002.jpg
case_images: fig2
case_images: The lesion appeared as a grayish nodule, hard and papillomatous (Figure 2(a)). Some comedo-like openings were also observed (Figure 2(b)). Bright papillomatous structures with bulbous projections, suggestive of a seborrheic keratosis, were recognizable in spite of a blurred appearance, due to the hyperkeratotic surface of the lesion, limiting the penetration depth of the laser beam (Figures 2(c) and 2(d)). The lesion was excised and histologically processed, and the pathology report was of a seborrheic keratosis (Figure 2(e)).
case_images: PMC2945651_03
case_images: Forehead of a 75-year-old woman. A bluish, ulcerated nodule (a). The dermoscopic images were characterized by the presence of blue-brown leaf-like structures (red arrows), with an area of ulceration in the center, surrounded by white bright lines, with a chrysalis structure aspect (white arrow) and some brownish and black globular-like structures all over the lesion (yellow asterisk) (b). Confocally, reflectant tumor islands with palisading cells at the periphery ((c) red arrows) and bright cells in their inner portion ((c) mosaic 1.5 x 1.5 mm; (d) detail 500 x 500 mum; yellow arrow), were present, mixed to thickened collagen fibers ((d) white arrow head). Histopathology confirmed the diagnosis of a BCC with a high correspondence, showing tumor islands ((e) HH 10x magnification, red arrow) and numerous melanophages (yellow arrow).
case_images: DRP2010-168248.003.jpg
case_images: PMC2945651_03_DRP2010-168248.003.jpg
case_images: fig3
case_images: Also, white and bright chrysalis structures were present under the polarized dermoscopy examination (Figure 3(a)). Confocally, reflectant tumor islands were seen, with palisading cells at the periphery and small bright cells in their inner portion, corresponding to inflammatory cells (Figures 3(b) and 3(c)). Many melanophages were also present in the upper dermis, in a context of thickened fibers of collagen (Figure 3(d)). The imaging was highly suggestive of a pigmented basal cell carcinoma, confirmed by histopathology with high correspondence (Figure 3(e)).