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The Ink Test: Identifying 3-Dimensional Features of Seborrheic Keratoses Under Dermoscopy

The Ink Test: Identifying 3-Dimensional Features of Seborrheic Keratoses Under Dermoscopy Correctly classifying a lesion under dermoscopy depends on the ability to categorize a lesion as either melanocytic or not. Report of a Case A 71-year-old man presented to clinic with 2 lesions on sun-damaged skin that were suggestive under dermoscopy of melanocytic lesions. The first lesion appeared to have a globular pattern (Figure 1A). The second lesion seemed to have a network pattern (Figure 1C). View LargeDownload Figure 1. Dermoscopic images. A and B, The globulelike structures (A) are due to pigmented comedolike openings (B) resembling globules under dermoscopy. C and D, The networklike structures (C) are due to comedo openings and crypts, gyri and/or sulci (D) arranged in such a manner as to look like a network. Comment Early seborrheic keratoses (SKs) and solar lentigines may reveal networklike structures or globulelike structures, resulting in their misclassification as melanocytic tumors when analyzed via the 2-step dermoscopy algorithm.1 This dermoscopic error comes from the limitation that the information received through the viewfinder of the dermoscope is converted from a 3-dimensional image to a 2-dimensional one. We propose the “ink test” to highlight the 3-dimensional morphologic characteristics of SKs when viewed under dermoscopy (Figure 1). Dermoscopic features of SKs have been successfully identified and include milialike cysts, comedolike openings or crypts, gyri and sulci creating networklike structures, moth-eaten borders, hairpin blood vessels, and sharp demarcation. Of the SK features, comedolike openings and gyri and sulci are examples of 3-dimensional structures that may prove difficult to identify under 2-dimensional dermoscopy, especially in early macular lesions and in lesions that are less heavily pigmented. Dermoscopic networklike and globulelike structures present in SKs are quite common with gyri and sulci present in 52% to 61% of lesions and comedolike openings present in 71% to 80%.2,3 These structures may be missed entirely or else confused for a pigment network or globules, which may lead to diagnostic uncertainty or misclassification as a melanocytic lesion. However, with use of the ink test, these features can be highlighted and clarified. The procedure that we have used to successfully and reliably identify these 2 elements is as follows: First, mark the lesion thoroughly with a felt-tipped surgical marking pen. Next, remove the ink from the surface of the lesion with an alcohol wipe. Finally, view the lesion under dermoscopy; the ink will remain within the sulci and comedolike openings. The image may be viewed side-by-side with an image taken from before the ink test to confirm that the inked areas align with previously classified areas of globules and/or network (Figure 2). View LargeDownload Figure 2. Dermoscopic images presented at a conference. A, At a recent dermoscopy conference with more than 200 participants, over 50% thought that the pictured lesion was a melanocytic tumor. B, After the ink test, over 90% of participants diagnosed this lesion as a seborrheic keratosis. The same process has been applied reliably to highlight the cornoid lamella in porokeratosis or in acral melanocytic lesions to distinguish the furrows of the skin from the ridges.4,5 With the expanded application of the ink test for the visualization of features of SKs, we hope to limit the misdiagnosis of SKs as melanocytic lesions. Back to top Article Information Correspondence: Dr Marghoob, Memorial Sloan-Kettering Skin Cancer Center Hauppauge, 800 Veterans Memorial Hwy, Second Floor, Hauppauge, NY 11788 (marghooa@mskcc.org). Conflict of Interest Disclosures: None reported. Additional Contributions: We would like to thank the dermatologists who attended the 2012 dermoscopy course at Memorial Sloan-Kettering Skin Cancer Center. References 1. Marghoob AA, Braun R. Proposal for a revised 2-step algorithm for the classification of lesions of the skin using dermoscopy. Arch Dermatol. 2010;146(4):426-42820404234PubMedGoogle ScholarCrossref 2. Rajesh G, Thappa DM, Jaisankar TJ, Chandrashekar L. Spectrum of seborrheic keratoses in South Indians: a clinical and dermoscopic study. Indian J Dermatol Venereol Leprol. 2011;77(4):483-48821727696PubMedGoogle ScholarCrossref 3. Braun RP, Rabinovitz HS, Krischer J, et al. Dermoscopy of pigmented seborrheic keratosis: a morphological study. Arch Dermatol. 2002;138(12):1556-156012472342PubMedGoogle ScholarCrossref 4. Braun RP, Thomas L, Kolm I, French LE, Marghoob AA. The furrow ink test: a clue for the dermoscopic diagnosis of acral melanoma vs nevus. Arch Dermatol. 2008;144(12):1618-162019075144PubMedGoogle ScholarCrossref 5. Uhara H, Kamijo F, Okuyama R, Saida T. Open pores with plugs in porokeratosis clearly visualized with the dermoscopic furrow ink test: report of 3 cases. Arch Dermatol. 2011;147(7):866-86821768494PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

The Ink Test: Identifying 3-Dimensional Features of Seborrheic Keratoses Under Dermoscopy

JAMA Dermatology , Volume 149 (4) – Apr 1, 2013

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References (5)

Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2013.2233
Publisher site
See Article on Publisher Site

Abstract

Correctly classifying a lesion under dermoscopy depends on the ability to categorize a lesion as either melanocytic or not. Report of a Case A 71-year-old man presented to clinic with 2 lesions on sun-damaged skin that were suggestive under dermoscopy of melanocytic lesions. The first lesion appeared to have a globular pattern (Figure 1A). The second lesion seemed to have a network pattern (Figure 1C). View LargeDownload Figure 1. Dermoscopic images. A and B, The globulelike structures (A) are due to pigmented comedolike openings (B) resembling globules under dermoscopy. C and D, The networklike structures (C) are due to comedo openings and crypts, gyri and/or sulci (D) arranged in such a manner as to look like a network. Comment Early seborrheic keratoses (SKs) and solar lentigines may reveal networklike structures or globulelike structures, resulting in their misclassification as melanocytic tumors when analyzed via the 2-step dermoscopy algorithm.1 This dermoscopic error comes from the limitation that the information received through the viewfinder of the dermoscope is converted from a 3-dimensional image to a 2-dimensional one. We propose the “ink test” to highlight the 3-dimensional morphologic characteristics of SKs when viewed under dermoscopy (Figure 1). Dermoscopic features of SKs have been successfully identified and include milialike cysts, comedolike openings or crypts, gyri and sulci creating networklike structures, moth-eaten borders, hairpin blood vessels, and sharp demarcation. Of the SK features, comedolike openings and gyri and sulci are examples of 3-dimensional structures that may prove difficult to identify under 2-dimensional dermoscopy, especially in early macular lesions and in lesions that are less heavily pigmented. Dermoscopic networklike and globulelike structures present in SKs are quite common with gyri and sulci present in 52% to 61% of lesions and comedolike openings present in 71% to 80%.2,3 These structures may be missed entirely or else confused for a pigment network or globules, which may lead to diagnostic uncertainty or misclassification as a melanocytic lesion. However, with use of the ink test, these features can be highlighted and clarified. The procedure that we have used to successfully and reliably identify these 2 elements is as follows: First, mark the lesion thoroughly with a felt-tipped surgical marking pen. Next, remove the ink from the surface of the lesion with an alcohol wipe. Finally, view the lesion under dermoscopy; the ink will remain within the sulci and comedolike openings. The image may be viewed side-by-side with an image taken from before the ink test to confirm that the inked areas align with previously classified areas of globules and/or network (Figure 2). View LargeDownload Figure 2. Dermoscopic images presented at a conference. A, At a recent dermoscopy conference with more than 200 participants, over 50% thought that the pictured lesion was a melanocytic tumor. B, After the ink test, over 90% of participants diagnosed this lesion as a seborrheic keratosis. The same process has been applied reliably to highlight the cornoid lamella in porokeratosis or in acral melanocytic lesions to distinguish the furrows of the skin from the ridges.4,5 With the expanded application of the ink test for the visualization of features of SKs, we hope to limit the misdiagnosis of SKs as melanocytic lesions. Back to top Article Information Correspondence: Dr Marghoob, Memorial Sloan-Kettering Skin Cancer Center Hauppauge, 800 Veterans Memorial Hwy, Second Floor, Hauppauge, NY 11788 (marghooa@mskcc.org). Conflict of Interest Disclosures: None reported. Additional Contributions: We would like to thank the dermatologists who attended the 2012 dermoscopy course at Memorial Sloan-Kettering Skin Cancer Center. References 1. Marghoob AA, Braun R. Proposal for a revised 2-step algorithm for the classification of lesions of the skin using dermoscopy. Arch Dermatol. 2010;146(4):426-42820404234PubMedGoogle ScholarCrossref 2. Rajesh G, Thappa DM, Jaisankar TJ, Chandrashekar L. Spectrum of seborrheic keratoses in South Indians: a clinical and dermoscopic study. Indian J Dermatol Venereol Leprol. 2011;77(4):483-48821727696PubMedGoogle ScholarCrossref 3. Braun RP, Rabinovitz HS, Krischer J, et al. Dermoscopy of pigmented seborrheic keratosis: a morphological study. Arch Dermatol. 2002;138(12):1556-156012472342PubMedGoogle ScholarCrossref 4. Braun RP, Thomas L, Kolm I, French LE, Marghoob AA. The furrow ink test: a clue for the dermoscopic diagnosis of acral melanoma vs nevus. Arch Dermatol. 2008;144(12):1618-162019075144PubMedGoogle ScholarCrossref 5. Uhara H, Kamijo F, Okuyama R, Saida T. Open pores with plugs in porokeratosis clearly visualized with the dermoscopic furrow ink test: report of 3 cases. Arch Dermatol. 2011;147(7):866-86821768494PubMedGoogle ScholarCrossref

Journal

JAMA DermatologyAmerican Medical Association

Published: Apr 1, 2013

Keywords: ink,keratosis, seborrheic,dermoscopy

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