doi: 10.1111/j.1346-8138.2010.01132.

x Journal of Dermatology 2011; 38: 53–58

INVITED ARTICLE

Key points in dermoscopic differentiation between

lentigo maligna and solar lentigo
Masaru TANAKA, Mizuki SAWADA, Ken KOBAYASHI
Tokyo Women’s Medical University Medical Center East, Tokyo, Japan

ABSTRACT
A clinical diagnosis of lentigo maligna at an early stage is often difficult even for experienced dermatologists. Differ-
ential diagnoses would include solar lentigo, early lesions of seborrheic keratosis, lichen planus-like keratosis,
pigmented actinic keratosis and melanocytic nevus. Dermoscopy has been shown to have higher diagnostic accu-
racy, especially in the diagnosis of pigmented skin lesions, in the past two decades. To aim of the present study
was to review the diagnostic key points on dermoscopy in the published work to differentiate lentigo maligna from
other differential diagnoses and reassess these important features on dermoscopy for specificity by describing the
findings in detail. Diagnostic key points for lentigo maligna ⁄ lentigo maligna melanoma on dermoscopy are asymmet-
rical pigmented follicular openings, rhomboidal structures, annular-granular structures and gray pseudo-network.
Lentigo maligna, at first, seems to occur as asymmetrical pigmented follicular openings and ⁄ or annular-granular
structures, then expand and develop into the rhomboidal structures. Annular-granular structures and gray pseudo-
network seem to be observed also in regressive areas of solar lentigo ⁄ initial seborrheic keratosis, lichen planus-like
keratosis and pigmented actinic keratosis. The four important criteria on dermoscopy for the diagnosis of lentigo
maligna have been reviewed, and the former two criteria seem to be more specific, but it might be difficult to recog-
nize these findings without misinterpretation. The latter two seem to be not so specific as they would also be
demonstrated in other pigmented epidermal lesions, although the distribution of the structures in these disorders
would be inclined to be more homogeneous than that of lentigo maligna.
Key words: annular-granular structures, asymmetrical pigmented follicular openings, dermoscopy, gray pseudo-network,
lentigo maligna, rhomboid structures.

INTRODUCTION criteria for most of the pigmented skin lesions includ-

Dermoscopy has been shown to have higher diag-
nostic accuracy, especially in the diagnosis of pig-
mented skin lesions, in the past two decades. A
clinical diagnosis of lentigo maligna (LM) at an early
stage is often difficult even for qualified and experi-
enced dermatologists. Differential diagnoses (DDx)
would include solar lentigo (SL) ⁄ initial seborrheic
keratosis (ISK), lichen planus-like keratosis (LPLK),
pigmented actinic keratosis (PAK) and melanocytic
nevus (MN). The Consensus Net Meeting on Dermo-
scopy (CNMD) in 20001,2 has revealed validation of
ing site-related features on facial melanocytic lesions
such as melanocytic nevus and LM ⁄ lentigo maligna
melanoma (LMM). Dermoscopic differentiation of
LM ⁄ LMM from SL ⁄ ISK is especially difficult. Schiff-
ner3 first described and depicted important dermo-
scopic findings for early recognition of LM ⁄ LMM
using dermoscopy. Following Schiffner’s description,
CNMD used four criteria for LM ⁄ LMM, namely, asym-
metrical pigmented follicular openings, rhomboidal
structures, annular-granular structures and gray
pseudo-network, for evaluations. It would be most
important to fully understand these four dermoscopic

Correspondence: Masaru Tanaka, M.D., Ph.D., Tokyo Women’s Medical University Medical Center East, 2-1-10 Nishi-Ogu, Arakawa-ku, Tokyo
116-8567, Japan. Email: masarutanaka@1984.jukuin.keio.ac.jp
Received 4 October 2010; accepted 6 October 2010.

 2011 Japanese Dermatological Association 53

M. Tanaka et al.

criteria for LM ⁄ LMM to be differentiated from SL ⁄ ISK,

LPLK, PAK and MN.

DIAGNOSTIC KEY POINTS FOR LM/LMM

Lentigo maligna clinically would be noted as a flat,
irregularly shaded dark brown to black macule on the
sun-damaged area of the face or scalp of elderly peo-
ple, relatively of short duration, however, much more
prolonged by comparison with the horizontal growth
phase of the superficial spreading melanoma. The
macule of LM tend to be much darker than SL and
irregularly pigmented, but yet non-elevated (Fig. 1).
This could be a useful diagnostic feature for LM to be
clinically differentiated from SL ⁄ ISK. LM is an in situ Figure 2. Asymmetrical pigmented follicular openings are
early dermoscopic sign of lentigo maligna and are often sur-
lesion of LMM and would eventually be invasive and rounded by slate-gray dark perifollicular pigmentation, which
life-threatening. Therefore, early detection of LM is would proceed to obliteration of hair follicles.
essential for appropriate treatment during the curable
stage. A partially elevated dark brown macule needs
to be differentiated from ISK occurring partially on the
SL, which would be inclined to demonstrate a rough
and keratotic plane. Meanwhile, LMM is predisposed
to exhibit a smooth surface to some extent even
when elevated.
Dermoscopy is particularly advantageous to find
early lesions of LM, demonstrating the characteristic
features of atypical pseudo-network, namely asym-
metrical pigmented follicular openings (Fig. 2),
rhomboidal structures (Fig. 3), annular-granular struc-
tures (Fig. 4) and gray pseudo-network (Fig. 5). Asym-

Figure 3. Dark rhomboidal structures are highly specific for

lentigo maligna ⁄ lentigo maligna melanoma. They first appear
as dark streaks or slate-gray dots in the vicinity of hair follicles
and then gradually form into the rhomboid pattern surround-
ing the follicles.

metrical pigmented follicular openings are due to an

Figure 1. Macule of lentigo maligna is of irregular pigmenta-
tion, partially very dark, yet non-elevated.
uneven descent of melanoma cells within individual
hair follicles.3 These are particularly specific, early
dermoscopic signs of LM and are often surrounded
by slate-gray dark streaks or perifollicular pigmenta-
tion, which would eventually proceed to obliteration
of some hair follicles (Fig. 2). The dark rhomboidal
structures would be seen in approximately 50%
of LM ⁄ LMM and, if present, are highly specific
for LM ⁄ LMM.3 They first appear as dark streaks or

54  2011 Japanese Dermatological Association


Figure 4. Annular-granular structures could be observed in
an early lesion of lentigo maligna as fine granular gray dots
encircling hair follicles.
Figure 5. Gray pseudo-network might be produced as a
result of regression process of lentigo maligna ⁄ lentigo malig-
na melanoma or other pigmented skin lesions. (Courtesy of
Dr K. Ohara, Toranomon Hospital, Tokyo, Japan.)
slate-gray dots in the vicinity of hair follicles and then
gradually form the rhomboid pattern surrounding the
follicles (Fig. 3). Annular-granular structures could be
observed in an early lesion of LM as fine, granular
gray dots encircling hair follicles (Fig. 4) or in the late
regressing stage of LM ⁄ LMM and other lesions as
fine or coarse, dark gray dots ⁄ globules. Since these
structures denote common features for regression,
some pigmented skin lesions, in their late stage,
might exhibit annular-granular structures, partly or
entirely to develop into gray pseudo-network (Fig. 5).
 2011 Japanese Dermatological Association
Dermoscopy of lentigo maligna
Figure 6. Lentigo maligna ⁄ lentigo maligna melanoma dem-
onstrates uneven distribution of slightly atypical melanocytes
mainly on the basal, but often in the upper layer of the atro-
phic epidermis and occasional formation of nests at the
dermoepidermal junction (hematoxylin–eosin, original magni-
fication ·400).
Figure 7. HMB-45 staining is helpful for a differential diagno-
sis from solar lentigo ⁄ initial seborrheic keratosis or pig-
mented actinic keratosis, confirming that the nests are
composed of melanocytes (original magnification ·200).
Histopathological key points for a diagnosis of
LM ⁄ LMM are uneven distribution of slightly atypical
melanocytes mainly on the basal, but often in the
upper layer of the atrophic epidermis and occasional
formation of nests at the dermoepidermal junction
(Fig. 6). Severe solar degeneration is usually present
in the upper dermis. HMB-45 (Fig. 7) or Melan-A
staining is particularly helpful for a DDx from SL ⁄ ISK
or PAK.
55
M. Tanaka et al.

DIFFERENTIAL DIAGNOSIS BETWEEN

SL/ISK AND LM/LMM

A clinical picture of irregular pigmentation of SL ⁄ ISK

on the face is sometimes indistinguishable from
LM ⁄ LMM, with only subtle difference in palpation or
rough surface (Fig. 8). Darker areas of SL ⁄ ISK are
often elevated and verrucous, while LM ⁄ LMM is likely
to have flat dark areas.

Figure 10. Dermoscopy of solar lentigo ⁄ initial seborrheic

keratosis also demonstrates features of light-brown finger-
print-like structures or milia-like cysts.

Dermoscopy greatly helps a correct diagnosis,

identifying features of comedo-like openings (Fig. 9),
diffuse opaque-brown pigmentation (Fig. 9), light-
brown fingerprint-like structures (Fig. 10) or milia-like
cysts (Fig. 10).

Figure 8. Clinical picture of irregular pigmentation of solar DIFFERENTIAL DIAGNOSIS BETWEEN

lentigo ⁄ initial seborrheic keratosis on the face is sometimes LPLK AND LM/LMM
indistinguishable from lentigo maligna ⁄ lentigo maligna mela-
noma, with only subtle differences in palpation or rough The clinical history often indicates that LPLK would
surface. probably occur on the pigmented macule on the face,

Figure 9. Dermoscopy greatly helps a correct diagnosis Figure 11. Classical type of lichen planus-like keratosis
of solar lentigo ⁄ initial seborrheic keratosis, finding features might be a slightly reddish, round, palpable lesion with a
of comedo-like openings or diffuse opaque-brown smooth or verrucous surface measuring up to 20 mm. (Cour-
pigmentation. tesy of Dr T. Doi, Osaka Rosai Hospital, Osaka, Japan.)

56  2011 Japanese Dermatological Association

 Dermoscopy of lentigo maligna

DIFFERENTIAL DIAGNOSIS BETWEEN MN

AND LM/LMM
Melanocytic nevus on the face is rarely misdiagnosed
as melanoma, while a very small macule of LM could
be regarded as MN (Fig. 13). However, the history
disclosed that this small dark macule on the face of a
61 year-old man had been noted for as short as
6 months.
Even with dermoscopy, this small LM simulates
MN of Miescher type, demonstrating the feature of a
rather typical pseudo-network at first glance (Fig. 14).

Figure 12. Dermoscopic features of lichen planus-like kera-

tosis are coarse or fine, gray to blue, granular dots and glob-
ules covering most of the lesion. A facial lesion consists of
light gray pseudo-network. (Courtesy of Dr T. Doi, Osaka
Rosai Hospital, Osaka, Japan.)

namely SL ⁄ ISK,4 but might include a heterogeneous

spectrum of epidermal or melanocytic pigmented
lesions.5 The classical type of LPLK might be a
slightly reddish, round, palpable lesion with a smooth
or verrucous surface measuring 5–20 mm (Fig. 11).
Dermoscopic features of average LPLK are coarse
or fine, gray to blue, granular pigmentation covering
most of the lesion. A facial lesion consists of gray but Figure 13. Very small macule of lentigo maligna could be
typical pseudo-network (Fig. 12). regarded as melanocytic nevus.

DIFFERENTIAL DIAGNOSIS BETWEEN PAK

AND LM/LMM
Pigmented actinic keratosis may clinically and
dermoscopically resemble LM ⁄ LMM and is some-
times indistinguishable.6 However, a scaly and rough
surface due to hyperkeratosis and parakeratosis
could be a clinical key point for differentiation in such
cases. When clinical and dermoscopic differentiation
is impossible and even histopathological findings are
delusive, immunohistochemical markers such as
Melan-A or HMB-45 would be crucial. When these
immunohistochemical stainings are performed, dou-
ble staining with Giemsa is recommended because
positive staining results and melanin depositions are Figure 14. Even with dermoscopy, this small lentigo maligna
simulates melanocytic nevus of Miescher type, demonstrat-
often mistaken. The Giemsa staining changes the
ing the feature of rather typical pseudo-network at first
color of melanin deposition into greenish and makes glance. Closer examination might permit presentation of dark
a positive reaction in the melanocytes discriminated globules inside the follicular openings, namely asymmetrical
from melanophages. pigmented follicular openings.

 2011 Japanese Dermatological Association 57

M. Tanaka et al.
Figure 15. Histopathological examination eventually estab-
lished a final diagnosis of lentigo maligna disclosing atypical
melanocytic proliferation with S-100 staining (original magni-
fication ·200).
Closer examination on the PC monitor would permit
exhibition of dark globules inside the follicular open-
ings, indicating asymmetrical pigmented follicular
openings.
A histopathological examination eventually estab-
lished a final diagnosis of an LM disclosing atyp-
58
ical melanocytic proliferation with S-100 staining
(Fig. 15).
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