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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 735-743

The role of dermoscopy in the recognition of dermatofibroma


1 Department of Dermatology and Venerology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
2 Third Doctor in the Medical Organization (for Girls), Al-Azhar University, Cairo, Egypt

Date of Submission31-Oct-2019
Date of Decision31-Oct-2019
Date of Acceptance18-Nov-2019
Date of Web Publication10-Feb-2020

Correspondence Address:
Zeinab M Faik
Nasr City Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_93_19

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  Abstract 


Introduction A central white scar-like patch and a delicate pigment network at the periphery are the typical signs of dermatofibromas (DFs) on dermoscopy.
Aim The aim was to analyze the different dermoscopic appearances of DF.
Patients and methods This study was carried out between June 2018 and June 2019 from the Dermatology Outpatient Clinic at Al Zahraa University Hospital, Al Sayed Galal University Hospital, and El-Hood El-Marsood Hospital, and included 50 cases of DF with 63 lesions of DF. Each lesion was examined by dermoscopy and histopathological examination was performed for suspicious lesions.
Results A typical pattern (central white scar-like patch and peripheral pigmented network) was observed in 49 of 63 (77.7%) lesions and variants from this typical pattern included peripheral homogeneous pigmentation and central white network in two (3%) lesions, multiple white patches with peripheral pigmented network in two (3%) lesions, central homogenous pigmentation and peripheral pigmented network in one (1%) lesion, and total pigmented network in one (1%) lesion, whereas an atypical pattern, which was named the ‘nonDF-like’ pattern (1%), was seen in 14 of 63 lesions (22.2%). Atypical DFs showed features resembling different conditions such as melanoma in two (3%) lesions, psoriasis-like pattern in one (1%) lesion, basal cell carcinoma in one (1%) lesion, squamous cell carcinoma in one (1%) lesion, and aneurysmal in one (1%) lesion. Vascular patterns in our study were found in three (5%) lesions, which had a linear and dotted pattern.
Conclusion DFs may display different morphological faces. The typical dermoscopic patterns allow a confident diagnosis, whereas a full surgical excision is always recommended in all doubtful cases.

Keywords: atypical dermoscopic patterns, dermatofibroma, dermoscopy, typical dermoscopic patterns, Variants


How to cite this article:
Elshahed LH, El-Sebaei HK, Faik ZM. The role of dermoscopy in the recognition of dermatofibroma. Sci J Al-Azhar Med Fac Girls 2019;3:735-43

How to cite this URL:
Elshahed LH, El-Sebaei HK, Faik ZM. The role of dermoscopy in the recognition of dermatofibroma. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Oct 24];3:735-43. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/735/278056




  Introduction Top


Dermatofibroma (DF) is a common, benign dermal proliferation, clinically appearing as a firm, occasionally pigmented papule, plaque or nodule, with a smooth or a keratotic surface and variable size (≥2 cm) [1]. DFs may be brown, red-brown, black, yellow, or ivory [2]. Lateral compression can produce a dimple-like depression in the overlying skin. The leg is the most common site of involvement [3].

Histologically, DF is composed of a mixture of fibroblast-like spindle cells, histiocytes, and blood vessels in varying proportions. The epidermis is usually hyperplastic and frequently shows hyperpigmentation of the basal layer. Numerous histopathologic variants have been described, such as aneurysmal DF and other variants [2].

Dermoscopy is a standard procedure whose benefits in the diagnosis and management of pigmented skin tumors have been largely proven in the last few years [1].

Central white scar-like patch and a delicate pigment network at the periphery have been described as the typical appearance of DFs on dermoscopy [2].


  Aim Top


We aimed to analyze the different dermoscopic appearances of DFs.


  Patients and methods Top


Participation in this study was not obligatory. The included cases were informed about the aim of the study and informed written consent was obtained from the patients before enrollment in the study. The study was approved by the Dermatology Research Ethical Committee, Faculty of Medicine for Girls, Al Azhar University.

We carried out a descriptive and analytical study of digital dermoscopic images of DF prospectively collected in the Dermatology Outpatient Clinic at Al Zahraa University Hospital, Al Sayed Galal University Hospital, and El-Hood El-Marsood Hospital during a period of 1 year from June 2018 to June 2019. Fifty Egyptian patients were enrolled in the study. Some patients had multiple lesions; thus, the total number of lesions was 63 DFs. Patients of both sexes were included in our study and they were older than 15 years of age. Exclusion criteria included patient refusal of participation in the work. DF was confirmed either by clinical findings in common DF with the classic dermoscopic pattern of peripheral pigment network and central white scar-like patch. Histopathological examination was performed for suspicious and atypical lesions.

Clinical data were obtained for each patient, including age and sex as well as the phototype, location, color, number, and size of the lesions. Dermoscopic images were documented using a DermLite dermoscope (DermaLite hud 3Gen, American, USA) at 10-fold magnification. Clinical and dermoscopic images of atypical variants of DF confirmed on the basis of histology were analyzed retrospectively after excision.


  Results Top


A total of 50 patients, 43 (86%) females and seven (14%) males, ranging in age from 16 to 69 years (median age was 34.02 years), with a clinical and dermoscopic diagnosis of DF were evaluated. The total number of DFs was 63; a single lesion was observed in 44 (88%) patients, whereas six (12%) patients presented with two or more DFs. The most common skin phototype among the studied cases was type IV (37 of cases) (63%). The most common color of DFs was brown (53 lesions) (84%). Of the 63 DF lesions, 32 (51%) lesions were located on the lower limbs, 20 (32%) on the upper limbs, five (8%) on the anterior trunk, and six (9%) on the buttocks and posterior trunk. A total of 45 (71%) lesions of DFs were less than 1 cm and 18 (29%) lesions were more than or equal to 1 cm. Histologic examinations were performed in five (29.4%) lesions that confirmed the diagnosis of DFs. Papular lesions were the most common clinical pattern (44 of lesions) (69.8%) ([Table 1]). There was a significant relationship between the classic pattern and female sex.
Table 1 Data of studied cases

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A total of 10 morphological dermoscopic structures were evaluated. Pigmented network was observed in 49 (77%) lesions, white scar-like patch in 45 (71%) lesions, homogeneous pigmentation in 13 (21%) lesions, a white network in four (6%) lesions, globule-like structures in two (3%) lesions, peripheral rings around follicular openings in one (1%) lesion, scales in four (6%) lesions, and vascular structures in three (4.7%) lesions ([Table 2]) (1).
Table 2 Morphological dermoscopic patterns according to Ferrari et al. [1]

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Eight dermoscopic patterns were observed, which can be divided into two categories is given in [Table 3] (4).
Table 3 Dermoscopic patterns in our study according to Zaballos et al. [4]

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Dermoscopic patterms of DF can be simplified as given in [Figure 1] (4).
Figure 1 Schematics and frequency of the different dermoscopic patterns in dermatofibromas. (1) total delicate pigment network; (2) peripheral delicate pigment network and central white scar-like patch; (3) peripheral delicate pigment network and central white network; (4) peripheral delicate pigment network and central homogeneous area; (5) total white network; (6) total homogeneous area; (7a) total white scar-like patch; (7b) multiple white scar-like patches; (8) peripheral homogeneous area and central white scar-like patch; (9) peripheral homogeneous area and central white network; (10) atypical pattern.

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Patterns with a peripheral pigmented network

Central white scar-like patch and peripheral pigment network are considered the classic pattern. It is the most common pattern observed in our series in 44 (70%) lesions ([Figure 2]). Two (3%) of these central white patches had a star-shaped pattern ([Figure 3]), six (10%) lesions of this classic pattern showed globule-like structures ([Figure 4]), scales were observed in three (5%) of lesions after scale removal, and central scar-like patch with peripheral pigmented network appeared ([Figure 5]), whereas ulcerations were present in two (3%) of lesions ([Figure 6]) and streaks in one (1%) lesion of DFs ([Figure 7]). Milia-like cysts were observed in one (1%) lesion ([Figure 8]).
Figure 2 Classic type: central white patch and peripheral pigment network.

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Figure 3 Central scar-like patch (star shaped) with peripheral pigmented network.

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Figure 4 Pigmented network and central scar-like white patch with central globule-like structures.

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Figure 5 Psoriasis-like pattern before removal of scales.

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Figure 6 Classic pattern with central ulceration.

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Figure 7 Classic pattern with streaks.

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Figure 8 Classic pattern with milia-like cysts at the periphery.

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Multiple white patches with a peripheral pigmented network were observed in three (5%) lesions. Two of them were located in the center of the lesion ([Figure 9]), whereas the other one (1%) was eccentric ([Figure 10]).
Figure 9 Multiple central scar-like patches with peripheral pigmented network.

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Figure 10 Eccentric scar-like patches.

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Central homogenous pigmentation and peripheral pigmented network were observed in six (10%) lesions of DFs. The central homogenous pigmentation was bluish in two (3%) lesions and they also showed a globule-like pattern. These two lesions were excised to rule out a malignant melanoma ([Figure 11]). The histopathologic examination showed DF; one (1%) lesion showed pinkish coloration ([Figure 12]).
Figure 11 Central homogenous pigmentation with peripheral pigmented network (melanoma-like pattern).

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Figure 12 Central pinkish homogenous pigmentation with peripheral pigmented network.

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Total pigmented network was found in one dermatofibroma leion. It showed a lentigo-like pattern and also showed rings around follicular openings ([Figure 13]).
Figure 13 Total pigmented network with rings around follicular openings.

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Patterns without peripheral pigmented network included the following:

A central white scar-like patch with peripheral homogenous pigmentation was observed in one (1%) lesion ([Figure 14]) and peripheral homogeneous pigmentation and central white network were observed in two (3%) lesions ([Figure 15]). Total homogenous pigmentation was observed in one (1%) lesion (lentigo-like pattern).
Figure 14 Central scar-like patch with peripheral homogenous pigmentation.

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Figure 15 Peripheral homogenous pigmentation and central white network.

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Aneurysmal pattern included central diffuse homogenous bluish pigmentation with peripheral brown pigmentation. It was present in one (1%) lesion ([Figure 16]). It was excised and histopathological examination indicated an aneurysmatic DF.
Figure 16 Aneurysmal dermatofibroma.

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Atypical pattern (squamous cell carcinoma like) shows multiple scar-like patches, central yellowish pigmentation, and linear blood vessel with peripheral pigmentation. The histopathological examination indicated a sclerotic DF. It was present in two (3%) lesions ([Figure 17]).
Figure 17 Atypical (squamous cell carcinoma like). The histopathological examination showed a sclerotic dermatofibroma.

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Basal cell carcinoma-like pattern mimics nodular basal cell carcinoma clinically; dermoscopic examination indicated DF: central scar-like patch with peripheral pigmented network. It was present in one (1%) lesion ([Figure 18]).
Figure 18 Basal cell carcinoma-like pattern.

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Vascular patterns in our study were found in five (8%) lesions. Two of these had a dotted pattern and the other three had a linear pattern ([Figure 19] and [Figure 20]).
Figure 19 Vascular structure in dermatofibromas with linear blood vessels.

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Figure 20 Dotted blood vessels in dermatofibroma.

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  Discussion Top


On the basis of our results, the typical dermoscopic pattern was the most frequently seen in our DFs. The typical pattern characterized by a peripheral delicate pigment network and central white scar-like patch was observed in most of our cases (70%) [1]. The pattern of a pigmented peripheral network and a central white scar-like patch was the most stereotypical and common finding of DF. This was also found in most of the cases in the study carried out by Ferrari et al. [1] (70%). This pattern was found in 62% of the cases in the study of Agero et al. [5] and 34% in the study of Zaballos et al. [4], whereas it was noted in only 21% of the cases in the study carried out by Kelati et al. [6]. This may be explained by the particularity of the skin of their population, which was of dark type. Wide variation of patterns has been described in the literature and in the Kelati et al. [6]. work on DFs, although some of these patterns are very rare, such as the total white scar-like patch and the seborrheic keratosis-like pattern [4],[7], but these rare variants were not noted in our study. These must be considered possible presentations of this tumor to increase diagnostic accuracy.

The white scar-like patch is defined as a more or less irregularly outlined and sharply demarcated white area. The results of the study carried out by Zaballos et al. [4] showed a white scar-like patch in (57%) of DFs that was mainly seen in the center of the lesion (74.5%). In the study by Ferrari et al. [1], the most frequent dermoscopic criterion was the central white scar-like patch that was described in 91.6% of DFs. Agero et al. [5] found a central white network in 84% of DFs using polarized contact dermoscopy, whereas in our study, it represented 45 of our dermatofibromas.

Peripheral homogeneous pigmentation and central white network were found in three (5%) lesions of our DFs. It was also found in the study carried out by Zaballos et al. [4]. Agero et al. [5] found a central white network in 84% of DFs using polarized contact dermoscopy. It was found in 4.6% of DFs in the study carried out by Ferrari and colleagues. It was found in 1% of cases in the study carried out by Kelati et al. [6].

Peripheral delicate pigment network and central homogeneous pigmentation were found in six (10%) lesions of our DFs. It was found in 3.8% of DFs in the study carried out by Ferrari and colleagues and 34.7% of DFs in the study carried out by Zaballos et al. [4]. The higher percentage in the study carried out by Zaballos et al. [4] may be explained by higher number of cases compared with our study and other studies. In our cases, the central homogenous pigmentation had a bluish coloration. The lesions were excised to rule out a malignant melanoma. The histopathologic examination indicated DF.

Multiple white scar-like patches with a peripheral pigmented network were found in two (3%) lesions of our DFs. These multiple white scar-like patch patterns were also found in 3.8% of DFs in the study carried out by Ferrari et al. [1]. This variant was also noted in 16% of the cases in the study carried out by Zaballos et al. [4].

Total delicate pigment network was found in one (1%) lesion in our study. It was found in 3.1% of DFs in the study carried out by Ferrari et al. [1] and 14.6% in the study of Zaballos et al. [4]. In our study, we found rings around follicular openings in a dark-skinned patient, which was in agreement with Kelati et al., who also found this structure in dark-skinned patients [6].

In our study, we also observed 14 (22.2%) lesions of DFs showing atypical patterns. These atypical patterns included melanoma, psoriasis, basal cell carcinoma, squamous cell carcinoma, and aneurysmal-like patterns.

These atypical patterns were also noted in the study carried out by Ferrari and colleagues in 29.2% of DFs and were found in a lower percentage of cases compared with Zaballos’ findings [4]. Different from Zaballos and colleagues, who described atypical DFs as showing an atypical pigment network, atypical scar-like patch, atypical homogeneous pigmentation, or their irregular distribution within the lesion [4], we considered atypical as all cases displaying a pattern that was named as the ‘non DF-like’ pattern. They specified this pattern on the basis of the specific features observed inside the lesion resembling a melanoma, a BCC, a vascular tumor, or psoriasis [1].

Multicomponent melanoma-like pattern was observed that represented melanoma in two (3%) of our lesions. It was found in 6.1% of the cases in the study carried out by Zaballos et al. [4], 29.2% of cases in the study of Ferrari et al. [1], and 20% of cases in the study of Kelati et al. [6] Histopathological examination was performed and indicated DF.

The misdiagnosis of DFs as melanocytic lesions is important, owing to the fact that the patterns significantly related to this benign tumor were characterized by pigmented features such as a pigment network, homogeneous pigmentation with a peripheral pigment network, a lentigo-like pattern, or total homogeneous pigmentation [6]. This may be explained by the dark skin phototype of our patients, which increased the need for better characterization of DF in the dark phototype.

Psoriasis-like pattern was noted in one of our lesions (1%); it was also found in 2.3% of lesions in the study carried out by Ferrari et al. [1]. The aneurysmal pattern was found in one of our lesions (1%), the lentigo-like pigment network was found in two of our lesions (3%), and it was also noted in 23% of the cases in the study carried out by Karaarslan et al. [2] and 12% of cases in the study of Kelati et al. [6].

Basal cell carcinoma in one (1%) lesion was also found in 4.6% of lesions in the study carried out by Ferrari et al. [1]; the squamous cell carcinoma-like pattern was found in one (1%) lesion of our DFs.

Vascular patterns in our study were found in five (8%) lesions, which were linear and dotted. One of these vascular structures was noted in aneurysmal DF, the second was seen in sclerotic DF, and the third in typical DF. Also, the dotted vascular pattern was observed in two of our cases with ulceration. Kelati et al. [6] mentioned that the presence of vascular structures was noted in aneurysmal DFs in his study. Blood vessels were observed in 44% of DFs in the study by Agero et al. [5] when polarized contact dermoscopy was used. These authors also found a central pink hue in 10% of the cases and a peripheral diffuse pinkish or reddish area in 28% of the cases using polarized contact dermoscopy. Zaballos et al. [4] found vascular structures in 49.5% of DFs. The most common vascular structure seen in their cases was erythema (31.5%), followed by dotted vessels (30.6%). The comparison between our patterns and other studies is shown in the following table.


  Conclusion Top


In conclusion, DF is a skin neoplasm that is usually easy to diagnose clinically and dermoscopically, but in some cases, its differentiation from other tumors may be difficult. The main dermatoscopic pattern in our DFs was Central white patch and peripheral pigment network, which is considered the classic pattern. Furthermore, other patterns were observed such as multiple white patches with a peripheral pigmented network, central homogenous pigmentation and peripheral pigmented network, total pigmented network, central scar-like patch with peripheral homogenous pigmentation, and central diffuse homogenous bluish pigmentation with peripheral brown pigmentation; other atypical variants were also observed.

The knowledge of the dermoscopic variability of DF, coupled with a careful clinical examination that usually reveals the characteristic dimple sign, usually allows the recognition of atypical variants of DF. However, a skin biopsy might be necessary in doubtful cases to rule out malignant tumors.

Recommendations

We recommend the use of dermoscopy as a routine investigation to improve our diagnostic capabilities for DF patients. We also recommend histopathological examination for all cases and their correlation with dermoscopic findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ferrari A, Argenziano G, Buccini P, Cota C, Sperduti I, De Simone P et al. Typical and atypical dermoscopic presentations of dermatofibroma. J Eur Acad Dermatol Venereol 2013; 27:1375–1380.  Back to cited text no. 1
    
2.
Karaarslan K, Gencoglan G, Akalin T, Ozdemir F. Different dermoscopic faces of dermatofibromas. J Am Acad Dermatol 2007; XX:57401–57406.  Back to cited text no. 2
    
3.
Meffert JJ, Peake MF, Wilde JL. ‘Dimpling‘ is not unique to dermatofibromas. Dermatology 1997; 195:384–386.  Back to cited text no. 3
    
4.
Zaballos P, Puig S, Llambrich A, Malvehy J. Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol 2008; 144:75–78.  Back to cited text no. 4
    
5.
Agero ALC, Taliercio S, Dusza SW, Salaro C, Chu P, Marghoob AA. Conventional and polarized dermoscopy features of dermatofibroma. Arch Dermatol 2006; 142:1431–1437.  Back to cited text no. 5
    
6.
Kelati A, Aqil N, Baybay H, Gallouj S, Mernissi FZ. Beyond classic dermoscopic patterns of dermatofibromas: a prospective research study. J Med Case Rep 2017; 11:266.  Back to cited text no. 6
    
7.
Piccolo V, Mascolo M, Russo T, Russo D, Baroni A. Dermatofibroma with seborrheic keratosis-like changes: a dermoscopic challenge. J Am Acad Dermatol 2014; 71:123–124.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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