Confocal microscopy in the diagnosis of pink facial lesions

Received on: 10 February 2013
Approved on: 7 March 2013

The present study was carried out at a private
practice—São Paulo (SP), Brazil.

Financial support: None
Conflict of interest: None

Abstract

Solitary pink lesions of the face may have nonspecific dermoscopic patterns, and are thus deemed difficult to diagnose. Differential diagnoses to consider are: actinic keratosis, squamous cell carcinoma, basal cell carcinoma, and amelanotic melanoma. Confocal microscopy can be used as an auxiliary clinical examination in their diagnosis and in determining the most significant sites for carrying out a biopsy. The authors describe a case that illustrates the usefulness of a confocal microscopy examination in pink lesions.

Keywords: DERMOSCOPY, MICROSCOPY, CONFOCAL, CARCINOMA, BASAL CELL, KERATOSIS ACTINIC

CASE REPORT

A 61-year-old white female patient reporting intense exposure to the sun in childhood and adolescence presented with a complaint of a wound in the nasal tip for four months. She described having undergone cauterization two years before, developing with reddened area in the site.

At the dermatological examination the patient presented an erythematous papule of approximately 4mm and with a central meliceric crust (Figure 1).

At the dermoscopic examination a pinkish area with fine telangiectasias and central exulceration was noticed (Figure 2). Diagnoses of actinic keratosis or basal cell carcinoma (BCC) were hypothesized. In the face of diagnostic uncertainty and due to the fact that the lesion was located in a critical area from an aesthetic perspective, the authors decided to carry out a confocal microscopy examination in order to obtain a better diagnosis before choosing the treatment to follow. Through confocal microscopy it was possible to visualize areas whose epidermis presented keratinocytes with polarized nuclei and crusts. In the dermal-epidermal junction (DEJ) and dermis there were tumor islands with clefts surrounded by dense collagen fibers and linear vessels of great diameter (Figures 3 and 4). The confocal microscopy examination in vivo was consistent with the BCC diagnosis.1 In the face of this suspicion, a biopsy was carried out in the most significant region of the examination, revealing a sclerodermiform BCC. Due to the histologic type and location of the lesion, Mohs surgery was chosen.2 Transverse histological sections were carried out in the first stage 3 in the same plane where the dermoscopy and confocal microscopy were previously carried out (Figure 1). There was a high correlation between the findings of the Mohs biopsy and the confocal microscopy examination.

DISCUSSION AND CONCLUSION

The in vivo confocal microscopy examination is a noninvasive technique that assists in the diagnosis of nonspecific solitary pink lesions of the face, known as pink lesions. These lesions have the following conditions as the main differential diagnostic: actinic keratosis, squamous cell carcinoma, basal cell carcinoma and amelanotic melanoma.4 Dermoscopy often yields nonspecific patterns. Young patients are often times resistant to undergoing biopsy, especially in the face, therefore confocal microscopy arises as a valuable resource for defining the proper condition.

References

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2 . Terzian LR, Nogueira VMA, Paschoal FM, Barros JC, Machado Filho CD. Cirurgia microcrográfica de Mohs para preservação tecidual nas cirurgias oncológicas da face. Surg Cosmet Dermatol. 2010;2(4):257-63

3 . Rezze GG, Scramim AP, Neves RI, Landman G. Structural correlations between dermoscopic features of cutaneous melanomas and histopathology using transverse sections. Am J Dermatopathol. 2006;28(1):13-20

4 . Braga JC, Scope A, Klaz I, Mecca P, González S, Rabinovitz H, Marghoob AA. The significance of reflectance confocal microscopy in the assessment of solitary pink skin lesions. J Am Acad Dermatol. 2009;61(2):230-41