doi: 10.1111/1346-8138.

13657 Journal of Dermatology 2017; 44: 518–524

REVIEW ARTICLE
Dermoscopy–pathology relationship in seborrheic keratosis
Akane MINAGAWA
Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan

ABSTRACT
Making a definitive diagnosis of seborrheic keratosis (SK) can be challenging for the naked eye due to its wide
variation in clinical features. Fortunately, however, most cases of SK exhibit the typical dermoscopic findings of
fissures and ridges, hairpin vessels with white halo, comedo-like openings, and milia-like cysts, all of which are
helpful to distinguish SK from melanoma, melanocytic nevus, squamous cell carcinoma, basal cell carcinoma
(BCC) and other skin tumors. Histopathologically, these dermoscopic characteristics correspond to papillomatous
surface of the epidermis, enlarged capillaries of the dermal papillae, pseudohorn cysts in the epidermis opened to
the surface of the lesion and intraepidermal cysts, respectively. Clinicians should bear in mind that the clonal type
of SK dermoscopically mimics melanoma and BCC by the presence of globule-like structures, while regressing
SK exhibits a granular pattern that is similar to the peppering found in melanoma. Furthermore, milia-like cysts
alone are insufficient for a conclusive diagnosis of SK because melanoma in rare cases displays cysts along with
other SK-like dermoscopic findings.
Key words: dermoscopy, histopathology, melanoma, milia-like cysts, seborrheic keratosis.

INTRODUCTION Fissures and ridges

Seborrheic keratosis (SK) is one of the most frequently
encountered cutaneous neoplasms in clinical practice. When
appearing with typical characteristics, such as a light brown
to brown nodule with a papillomatous and/or scaly surface,
the diagnosis of SK is easily established, even with the
naked eye. However, SK varies in color (skin color to heavily
pigmented) and shape (flat macule to nodule or cutaneous
horn) and is occasionally influenced by irritation or inflamma-
tion, all of which can mimic the appearance of other skin
tumors, such as melanoma, melanocytic nevus, squamous
cell carcinoma (SCC) and basal cell carcinoma (BCC), and
complicate diagnosis. In most cases, dermoscopy is helpful
to distinguish SK from other cutaneous neoplasms based on
established characteristic findings.1,2 This report describes
the typical dermoscopic features of SK along with their
histopathological correlations. The dermoscopic mimics of SK
are also presented.
DERMOSCOPIC FINDINGS IN SK AND THEIR
HISTOPATHOLOGICAL CORRELATIONS
The dermoscopic findings of SK are presented according to
Kittler et al.3 Corresponding histopathological correlations are
described (Fig. 1) with reference to Takenouchi4 and Ferrara
et al.5
Former synonyms for fissures and ridges are “gyri and sulci”
and “fat finger” to describe thick, curved, occasionally
branched lines whose colors vary from hypopigmented to
brown, black and blue (Fig. 2). The term fat finger is more
applicable for flat and slightly elevated areas of lesions (Fig. 3),
in contrast to fissures and ridges being frequently used to
describe nodular regions. When spread throughout the lesion,
this finding gives a cerebriform, or brain-like, appearance. The
histopathological correlation of fissures and ridges is a papillo-
matous surface of the epidermis. The fat finger in early SK
lesions can be confusingly similar in some cases to the pig-
ment network of melanocytic lesions, whose lines are typically
thinner and holes evenly distributed and small.6 The ink test is
useful to identify the 3-D structures of SK and may help differ-
entiate it from melanocytic lesions.7
Hairpin vessels
Also described as (linear) looped vessels, hairpin vessels are
defined as two parallel linear vessels forming a half-looped or
hairpin-like structure. The vessels are often surrounded by a
white halo when seen in such keratinocytic neoplasms as SK
and viral warts.8 Multiple monomorphous hairpin vessels with
white halo throughout the lesion suggests SK (Fig. 4). How-
ever, similar hairpin vessels can be observed in melanoma,
SCC, BCC and other cutaneous neoplasms. The definitive
diagnosis of SK should therefore be made including additional

Correspondence: Akane Minagawa, M.D., Ph.D., Department of Dermatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto,
Nagano 390-8621, Japan. Email: akn@shinshu-u.ac.jp
Received 12 September 2016; accepted 12 September 2016.

518 © 2017 Japanese Dermatological Association


Figure 1. Schematics of (a) dermoscopic and (b) histopatho-
logical findings of seborrheic keratosis.
Figure 2. Dermoscopic image of seborrheic keratosis present-
ing fissures and ridges (arrows) and comedo-like openings (ar-
rowheads).
dermoscopic findings of SK and not with hairpin vessels alone.
Our histopathological findings of a horizontally sectioned SK
specimen revealed hairpin vessels to histopathologically corre-
spond to enlarged capillaries of the dermal papillae (Fig. 5). It
has been suggested that the enlarged capillaries become
slanted due to a change in dermal papilla orientation, which
causes them to appear as hairpin vessels.9
Comedo-like openings
Comedo-like openings are round to oval clefts containing a
keratin plug that is generally dark brown, gray or black
(Figs 2,6). The term “crypts” is commonly used when the size
of the clefts are large. Comedo-like openings correspond
histopathologically to pseudohorn cysts in the epidermis that
are opened to the surface of the lesion.
© 2017 Japanese Dermatological Association
Dermoscopy–pathology relationship in SK
Figure 3. Dermoscopic image of early seborrheic keratosis
lesion presenting “fat fingers” (circle).
Figure 4. Dermoscopic image of seborrheic keratosis present-
ing hairpin vessels with white halo.
Milia-like cysts
Milia-like cysts are round, well circumscribed, white to yellow-
ish opalescent structures that histopathologically correspond
to intraepidermal cysts. These manifestations are more con-
spicuous when examined with non-polarized dermoscopy.10
Multiple milia-like cysts throughout the lesion is a characteristic
finding of SK that has been referred to as “stars in the sky”
(Fig. 6). However, these cysts do not always indicate SK. A
small number of milia-like cysts can be detected in melanocy-
tic nevus (Fig. 7), melanoma and BCC (Fig. 8). A large number
(>3) and small size (<1/3 mm) of cysts are particularly impor-
tant to differentiate SK from melanoma.11,12
519
A. Minagawa
(a)
(b) (c)
Figure 5. Histopathological image of seborrheic keratosis
shown in Figure 4. (a) Vertical section revealed an acanthotic
type of seborrheic keratosis. (b) Horizontal section 450 lm
below the surface of the lesion corresponded closely to
dermoscopic findings. (c) Tumor cells and stromal dermis
exhibited reticular formation and enlarged capillaries (hema-
toxylin–eosin, original magnifications: [a,b] 940; [c] 9200).
Figure 6. Dermoscopic image of seborrheic keratosis present-
ing comedo-like openings (arrows) and milia-like cysts (arrow-
heads).
520
Figure 7. Dermoscopic image of Unna nevus presenting
comedo-like openings (black arrows) and milia-like cysts (arrow-
heads). Comma vessels (white arrows) were the diagnositc clue.
Figure 8. Dermoscopic image of basal cell carcinoma present-
ing milia-like cysts (arrowheads). Arborizing vessels (white
arrows) and blue-gray dots (black arrow) were the diagnostic
clue.
DERMOSCOPIC FEATURES OF
HISTOPATHOLOGICAL VARIANTS OF SK
Acanthotic type
In the acanthotic type of SK, the epidermis is markedly thick-
ened and contains a number of pseudohorn cysts. As the most
common SK, the acanthotic type shows such typical dermo-
scopic SK findings as comedo-like openings, milia-like cysts
and hairpin vessels. However, this subtype may be difficult to
diagnose in highly pigmented lesions because dermoscopic
© 2017 Japanese Dermatological Association

Figure 9. Dermoscopic image of hyperkeratotic type sebor-
rheic keratosis. Hyperkeratosis and papillomatosis of the epi-
dermis were evident. Milia-like cysts (arrowheads) were the
diagnositc clue for seborrheic keratosis. Squamous cell carci-
noma could not be excluded due to the presence of polymor-
phous vessels (white arrow) by dermoscopy.
findings become masked by melanin deposition. Irritation or
prior trauma may also render dermoscopic findings atypical.
Hyperkeratotic type
Hyperkeratosis and papillomatosis of the epidermis are pro-
nounced in the hyperkeratotic type of SK (Fig. 9). The clinical
differential diagnosis of hyperkeratotic type SK includes viral
warts, solar keratosis and SCC. Dermoscopic examinations
that specifically focus on areas with minimal hyperkeratosis are
encouraged to identify fissures and ridges reflecting the
remarkable papillomatous change of the epidermis. When
accompanied with comedo-like openings and milia-like cysts,
the diagnosis of hyperkeratotic type SK is more probable than
that of viral warts, solar keratosis or SCC.
Reticulated type
In the reticulated type of SK, thin tracts of basaloid tumor cells
extend from the epidermis to the dermis while forming a reticu-
lar architecture. Reticulated type SK is considered to have a
close clinical and histopathological relationship with solar len-
tigo, and comparable findings for solar lentigo and early SK
may be observed under dermoscopy. To the best of our
knowledge, however, the detailed dermoscopic characteristics
of reticulated type SK have not been reported, presumably
because lesions that purely exhibit reticulated SK are rare.
Clonal type
In clonal type SK, well-circumscribed nests of basaloid tumor
cells often containing melanin deposits proliferate in the
© 2017 Japanese Dermatological Association
Dermoscopy–pathology relationship in SK
epidermis. When observed dermoscopically, the pigmented
intraepidermal nests appear as globule-like structures and are
almost indistinguishable from the blue-gray globules of BCC
and the dots/globules of melanocytic lesions.13–15 The pres-
ence of comedo-like openings and milia-like cysts together
with sharp lesion demarcation were reportedly helpful to diag-
nose clonal type SK. In the non-pigmented variety, the pres-
ence of polymorphous vessels that are glomerular, linear-
irregular and dotted along with a “white network” have been
reported.16 Histopathological examination is generally required
to confirm the diagnosis of the clonal type of SK.
Irritated type
Numerous squamous eddies and downward proliferation of the
epidermis are two histopathological characteristics of irritated
type SK lesions. According to Kitamura et al.,17 irritated type
SK tends not to exhibit the typical dermoscopic findings of SK,
such as comedo-like openings, milia-like cysts or monomor-
phous vascular patterns of hairpin vessels. Instead, small,
round, pinkish structures on a white background are the typical
dermoscopic findings of this SK subtype believed to corre-
spond to dilated vessels in the dermal papillae surrounded by
acanthotic tumor cells.
Regressing SK
This condition is generally regarded as lichenoid keratosis (LK)
or lichen planus-like keratosis histopathologically characterized
by a lichenoid reaction, namely, band-like infiltration of inflam-
matory cells in the upper dermis, pigment incontinence and
individual degenerated keratinocytes in the epidermis. Dermo-
scopically, LK exhibits a granular pattern typified by regularly
distributed coarse blue grayish or brownish gray dots
(Fig. 10).18,19 We also showed that the granular pattern dots in
the LK lesion histopathologically corresponded to melanin
granules in the dermis owing to pigment incontinence.20 Longi-
tudinal dermoscopic observation revealed that while areas dis-
playing the granular pattern gradually increased, those with
common dermoscopic findings of SK, such as comedo-like
openings, milia-like cysts, fissures and ridges, and hairpin ves-
sels, became decreased in regressing SK lesions.21 These
observations suggest that some forms of LK may represent
SK in the process of regression. It should be noted that a
granular pattern alone is insufficient for the diagnosis of
regressing SK; LK also indicates other regressing cutaneous
neoplasms, including solar lentigo, Bowen disease and mela-
noma.
Melanoacanthoma
Melanoacanthoma is a heavily pigmented variant of SK
histopathologically characterized by increased large, dendritic,
melanin-rich melanocytes throughout the tumor. The heavy pig-
mentation of melanoacanthoma masks dermoscopic findings,
rendering it almost impossible to differentiate this condition from
melanoma and other pigmented skin lesions. Although the pres-
ence of typical dermoscopic SK features were helpful for diagno-
sis in past cases, histopathological examination was deemed
indispensable to exclude melanoma.22–24
521
A. Minagawa
(a)
(b)
Figure 10. (a) Dermoscopic image of regressing seborrheic ker-
atosis presenting granular pattern. (b) Histopathological examina-
tion revealed the band-like infiltration of inflammatory cells in the
upper dermis, pigment incontinence and individual degenerated
keratinocytes in the epidermis. Atypical cells were not detected
in the lesion (hematoxylin–eosin, original magnification 940).
DERMOSCOPIC MIMICS OF SK
Melanoma
One of the major dermoscopic pitfalls of SK is melanoma
(Fig. 11). Several accounts of SK-like melanoma have been
reported to date. Three cases dermoscopically exhibited
comedo-like openings with no accompanying pigment network,
while two cases showed irregularly distributed dots/globules
with verrucous change of the lesion surface.25–29 The authors
emphasized that histopathological examination should be
always considered to avoid overlooking melanoma in lesions
containing dermoscopic features not classified as typical SK or
exhibiting clinical evolutions in color, size or other factors.
Spitz nevus/Spitzoid melanoma
Regularly distributed streaks in a starburst pattern at the periph-
ery of the lesion are generally considered as a characteristic der-
moscopic finding of pigmented Spitz nevus. However, we
recently encountered two cases of pigmented acanthotic type
SK demonstrating a similar starburst pattern.30 The histopatho-
logical correlation to the streaks was protrusions of the epider-
mis at the periphery of the lesion. Although careful observation
522
(a)
(b)
Figure 11. (a) Dermoscopic image of seborrheic keratosis-like
areas in melanoma. Comedo-like openings (arrowheads) and dots
and globules (arrows) were observed without pigment network on
the periphery of the lesion. Seborrheic keratosis was considered
based on this area. (b) Histopathological examination revealed
tumor cell nests and cysts in the epidermis that presumably cor-
responded to dots and globules and comedo-like openings,
respectively (hematoxylin–eosin, original magnification 940).
with dermoscopy revealed the presence of comedo-like open-
ings on the lesion surface in both cases, the existence of open-
ings alone was not sufficient to exclude melanoma (Fig. 12).11
When a starburst pattern is detected in adults, histopathological
examination is encouraged to exclude Spitzoid melanoma.31
Invasive SCC/keratoacanthoma
Irritation or trauma may alter the dermoscopic changes in SK
by the formation of a polymorphous vascular pattern, ulcera-
tion or crust. In addition to these dermoscopic findings indica-
tive of malignancy, when abnormal keratinization becomes
pronounced, the lesion is more likely to be SCC/keratoacan-
thoma.32 White circles, keratin and blood spots were reported
to differentiate SCC/keratoacanthoma from SK and other
raised non-pigmented skin lesions by dermoscopy.33
BCC
Dotted-, globule- or nested-like structures are not generally
seen in SK lesions by dermoscopy.2 Exceptions to this are the
globule-like structures observed in clonal type SK and the
globular pattern found in regressing SK, which may raise a
suspicion of BCC because they resemble the blue-gray
© 2017 Japanese Dermatological Association

(a)
(b)
Figure 12. (a) Dermoscopic image of seborrheic keratosis pre-
senting starburst pattern. (b) Histopathological examination
revealed acanthotic type seborrheic keratosis with heavy pig-
mentation (hematoxylin–eosin, original magnification 940). This
case was originally reported in Minagawa et al.30
globules and blue-gray ovoid nests of BCC. Another pitfall
requiring careful attention is collision of SK and BCC.34,35
ACKNOWLEDGMENT: This work was supported by JSPS
KAKENHI (Grant No. JP 15K19684).
CONFLICT OF INTEREST: None declared.
REFERENCES
1 Chen LL, Dusza SW, Jaimes N, Marghoob AA. Performance of the
first step of the 2-step dermoscopy algorithm. JAMA Dermatol
2015; 151: 715–721.
2 Braun RP, Rabinovitz HS, Krischer J et al. Dermoscopy of pig-
mented seborrheic keratosis: a morphological study. Arch Dermatol
2002; 138: 1556–1560.
3 Kittler H, Marghoob AA, Argenziano G et al. Standardization of ter-
minology in dermoscopy/dermatoscopy: results of the third consen-
sus conference of the International Society of Dermoscopy. J Am
Acad Dermatol 2016; 74: 1093–1106.
4 Takenouchi T. Key points in dermoscopic diagnosis of basal cell
carcinoma and seborrheic keratosis in Japanese. J Dermatol 2011;
38: 59–65.
© 2017 Japanese Dermatological Association
Dermoscopy–pathology relationship in SK
5 Ferrara G, Argenziano G, Soyer HP, Staibano S, Ruocco E, De
Rosa G. Dermoscopic-pathologic correlation: an atlas of 15 cases.
Clin Dermatol 2002; 20: 228–235.
6 Kopf AW, Rabinovitz H, Marghoob A et al. “Fat fingers:” a clue in
the dermoscopic diagnosis of seborrheic keratoses. J Am Acad
Dermatol 2006; 55: 1089–1091.
7 Yagerman S, Marghoob AA. The ink test: identifying 3-dimensional
features of seborrheic keratoses under dermoscopy. JAMA Derma-
tol 2013; 149: 497–498.
8 Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricala C, Argen-
ziano G. How to diagnose nonpigmented skin tumors: a review of
vascular structures seen with dermoscopy: part II. Nonmelanocytic
skin tumors. J Am Acad Dermatol 2010; 63: 377–386.
9 Ahlgrimm-Siess V, Cao T, Oliviero M, Hofmann-Wellenhof R, Rabi-
novitz HS, Scope A. The vasculature of nonmelanocytic skin tumors
in reflectance confocal microscopy, II: vascular features of sebor-
rheic keratosis. Arch Dermatol 2010; 146: 694–695.
10 Braun RP, Scope A, Marghoob AA. The “blink sign” in dermoscopy.
Arch Dermatol 2011; 147: 520.
11 Menzies SW, Kreusch J, Byth K et al. Dermoscopic evaluation of
amelanotic and hypomelanotic melanoma. Arch Dermatol 2008;
144: 1120–1127.
12 Stricklin SM, Stoecker WV, Oliviero MC, Rabinovitz HS, Mahajan
SK. Cloudy and starry milia-like cysts: how well do they distinguish
seborrheic keratoses from malignant melanomas? J Eur Acad Der-
matol Venereol 2011; 25: 1222–1224.
13 Hirata SH, Almeida FA, Tomimori-Yamashita J, Enokihara MS,
Michalany NS, Yamada S. “Globulelike” dermoscopic structures in
pigmented seborrheic keratosis. Arch Dermatol 2004; 140: 128–129.
14 Zalaudek I, Ferrara G, Argenziano G. Clonal seborrheic keratosis: a
dermoscopic pitfall. Arch Dermatol 2004; 140: 1169–1170.
15 Longo C, Zalaudek I, Moscarella E et al. Clonal seborrheic kerato-
sis: dermoscopic and confocal microscopy characterization. J Eur
Acad Dermatol Venereol 2014; 28: 1397–1400.
16 Ramyead S, Diaz-Cano SJ, Pozo-Garcia L. Dermoscopy of clonal
seborrheic keratosis. J Am Acad Dermatol 2015; 73: e47–e49.
17 Kitamura S, Hata H, Imafuku K, Fujita Y, Shimizu H. Dermoscopic
findings of irritated seborrheic keratosis. J Eur Acad Dermatol
Venereol 2016; 30: e94–e96.
18 Elgart GW. Seborrheic keratoses, solar lentigines, and lichenoid ker-
atoses. Dermatoscopic features and correlation to histology and
clinical signs. Dermatol Clin 2001; 19: 347–357.
19 Zaballos P, Blazquez S, Puig S et al. Dermoscopic pattern of inter-
mediate stage in seborrhoeic keratosis regressing to lichenoid ker-
atosis: report of 24 cases. Br J Dermatol 2007; 157: 266–272.
20 Shirota S, Minagawa A, Koga H, Momose M, Uhara H, Okuyama R.
Brown nodule on the lower eyelid: a quiz – lichenoid keratosis. Acta
Derm Venereol 2015; 95: 1037–1039.
21 Zaballos P, Salsench E, Serrano P, Cuellar F, Puig S, Malvehy J.
Studying regression of seborrheic keratosis in lichenoid keratosis with
sequential dermoscopy imaging. Dermatology 2010; 220: 103–109.
22 Chung E, Marghoob AA, Carrera C, Marchetti MA. Clinical and der-
moscopic features of cutaneous melanoacanthoma. JAMA Dermatol
2015; 151: 1129–1130.
23 Rossiello L, Zalaudek I, Ferrara G, Docimo G, Giorgio CM, Argen-
ziano G. Melanoacanthoma simulating pigmented spitz nevus: an
unusual dermoscopy pitfall. Dermatol Surg 2006; 32: 735–737.
24 Shankar V, Nandi J, Ghosh K, Ghosh S. Giant melanoacanthoma
mimicking malignant melanoma. Indian J Dermatol 2011; 56: 79–
81.
25 Argenziano G, Rossiello L, Scalvenzi M et al. Melanoma simulating
seborrheic keratosis: a major dermoscopy pitfall. Arch Dermatol
2003; 139: 389–391.
26 Braga JC, Scope A, Klaz I, Mecca P, Spencer P, Marghoob AA.
Melanoma mimicking seborrheic keratosis: an error of perception
precluding correct dermoscopic diagnosis. J Am Acad Dermatol
2008; 58: 875–880.
27 Carrera C, Segura S, Palou J et al. Seborrheic keratosislike mela-
noma with folliculotropism. Arch Dermatol 2007; 143: 373–376.
523
A. Minagawa
28 Ohnishi T, Hamano M, Watanabe S. Clinically verrucous and histo-
logically discohesive melanoma. A case report with dermoscopic
and immunohistochemical observations. Australas J Dermatol 2014;
55: e21–e23.
29 Longo C, Moscarella E, Piana S et al. Not all lesions with a verru-
cous surface are seborrheic keratoses. J Am Acad Dermatol 2014;
70: e121–e123.
30 Minagawa A, Tanaka M, Koga H, Okuyama R. Pigmented sebor-
rheic keratosis showing starburst pattern. J Am Acad Dermatol
2016; 75: e11–e13.
31 Moscarella E, Lallas A, Kyrgidis A et al. Clinical and dermoscopic
features of atypical Spitz tumors: a multicenter, retrospective, case-
control study. J Am Acad Dermatol 2015; 73: 777–784.
524
32 Squillace L, Cappello M, Longo C, Moscarella E, Alfano R, Argen-
ziano G. Unusual dermoscopic patterns of seborrheic keratosis.
Dermatology 2016; 232: 198–202.
33 Rosendahl C, Cameron A, Argenziano G, Zalaudek I, Tschandl P,
Kittler H. Dermoscopy of squamous cell carcinoma and keratoacan-
thoma. Arch Dermatol 2012; 148: 1386–1392.
34 Zaballos P, Llambrich A, Puig S, Malvehy J. Dermoscopy is useful
for the recognition of benign-malignant compound tumours. Br J
Dermatol 2005; 153: 653–656.
35 Ferrara G, Zalaudek I, Cabo H, Soyer HP, Argenziano G. Collision
of basal cell carcinoma with seborrhoeic keratosis: a dermo-
scopic aid to histopathology? Clin Exp Dermatol 2005; 30:
586–587.
© 2017 Japanese Dermatological Association