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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 1  |  Page : 18-21

Acral subcorneal hematoma: Additional dermoscopic findings differentiating it from acral melanocytic lesions


1 Department of Dermatology and Venereology, Faculty of Medicine, Tanta University, Tanta, Egypt; Department of Dermatology and Venereology, Armed Forces Hospitals, Southern Region, Khamis Mushait, Saudi Arabia
2 Department of Dermatology and Venereology, Armed Forces Hospitals, Southern Region, Khamis Mushait, Saudi Arabia
3 Department of Dermatology and Venereology, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission11-Oct-2019
Date of Acceptance06-Mar-2020
Date of Web Publication04-May-2021

Correspondence Address:
Dr. Ahmed H Nassar
Department of Dermatology and Venereology, Faculty of Medicine, Tanta University, El-Geish Street, Tanta 31111, Egypt; Department of Dermatology and Venereology, Armed Forces Hospitals - Southern Region, Khamis Mushait, Saudi Arabia

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_63_19

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  Abstract 


Background: Acral subcorneal hematoma (ASH) is a dark-colored skin lesion of the palms and/or soles due to bleeding. ASH may be difficult to be clinically differentiated from acral melanocytic lesions, resulting in unnecessary biopsies. Few researches reported the importance of dermoscopy in differentiating ASH from acral melanocytic lesions. Purpose: This study aims at reporting the dermoscopic features in a series of ASH to facilitate precise diagnosis and to avoid performing unnecessary surgical techniques. Methods: Eighteen patients with ASH were studied. Dermoscopic images were obtained using a handheld dermoscope and a dermoscope-adopted phone camera. Paring test was performed on all lesions. Results: The preliminary diagnoses of the lesions were ASH in 55.6%, acral melanocytic nevi in 33.3%, and acral lentiginous melanoma in the remaining 11.1%. Dermoscopically, the lesion colors were red-black in 44.4%, black in 27.8%, and brown in the remaining 27.8%. The pigmentation patterns were homogeneous (structureless) in 55.6%, parallel ridge in 27.8%, and negative pseudonetwork in the remaining 16.6%. Over 44% of the lesions had red and/or brown globular satellites. Peripheral red lines with/without radial extensions were noticed around ASH in 55.6%. Paring led to complete removal of pigmentation in all ASH (100%), with the appearance of post-paring blood-tinged serum in 55.6%. No skin biopsies were performed. Conclusion: Although there is clinical similarity between ASH and acral melanocytic lesions, dermoscopy and paring test can facilitate a precise diagnosis and markedly decrease the need for unnecessary invasive procedures.

Keywords: Acral lentiginous melanoma, acral melanocytic nevi, dermoscopy, subcorneal hematoma


How to cite this article:
Nassar AH, Abu-Aliat AS, Hawwam SA. Acral subcorneal hematoma: Additional dermoscopic findings differentiating it from acral melanocytic lesions. J Dermatol Dermatol Surg 2021;25:18-21

How to cite this URL:
Nassar AH, Abu-Aliat AS, Hawwam SA. Acral subcorneal hematoma: Additional dermoscopic findings differentiating it from acral melanocytic lesions. J Dermatol Dermatol Surg [serial online] 2021 [cited 2021 May 12];25:18-21. Available from: https://www.jddsjournal.org/text.asp?2021/25/1/18/315333




  Introduction Top


Acral subcorneal hematoma (ASH) is a dark-colored skin lesion of the palms and/or soles due to bleeding that occurs often after intense sport activity or accidental blunt trauma.[1] Hence, adolescents and young adults comprise most patients with this entity. On the other hand, elderly patients with palm or sole injuries can produce similar lesions. A viral infection[2] and repetitive microtraumas from computerized playing devices[3] have also been reported as etiologies.

Clinically, ASH is characterized by a well-demarcated, roundish or irregularly shaped, sometimes linear or punctated, macule or nodule, with colors varying from blue-black to reddish-brown.[1] It may be clinically difficult to differentiate from acral melanocytic nevi (AMN) and acral lentiginous melanomas (ALM), leading to unnecessary invasive procedures.[4]

Dermoscopy is an in vivo noninvasive diagnostic technique that magnifies the skin in such a way that color and structure in the epidermis, dermoepidermal junction, and papillary dermis, which cannot be seen with the naked eye, become visible.[5],[6] The color seen through a dermoscope depends on various factors.[7],[8] The two main chromophores detected are melanin, which appears as a black, brown, bluish, or grayish color depending on its depth in the skin, and hemoglobin, which can exhibit red, bluish, or even purple tones, depending on its depth, degree of oxidation, and the presence or absence of thrombosis.[7],[8],[9] Few full researches reported the importance of dermoscopy in differentiating ASH from acral melanocytic lesions.[1],[10]

In this study, we reported the dermoscopic features in a series of ASH to facilitate precise diagnosis and to decrease the need for performing unnecessary surgical techniques.


  Methods Top


After approval of the research ethics committee, this study was conducted on 18 patients with ASH. All the patients involved were from the outpatient department of the Armed Forces Hospital-Southern Region, Khamis Mushait, Saudi Arabia, between March 2019 and August 2019. All patients were subjected to full history taking, general and dermatological examination, and dermoscopic evaluation for all lesions. A preliminary decision was made to biopsy two lesions with a doubtful clinical diagnosis of ALM before the dermoscopic evaluation.

Dermoscopy was performed for all lesions using a handheld dermoscope with ×10 magnification (DermLite DL II Hybrid; 3Gen Inc.; San Juan Capistrano, CA 92675, USA). Dermoscopic images were obtained with a dermoscope-adopted phone camera with a high resolution (Galaxy Note 9, Samsung, South Korea). Paring (scratch/scraping) test was performed for 17 lesions using scalpel blades under sterile conditions. The remaining lesion was scraped by the patient's fingernail.


  Results Top


The current study was conducted on 18 lesions which were obtained from 14 males and 4 females. Patients' age ranged from 14 to 65 years with a mean±standard deviation of 32±17.5. Seventeen patients (94.4%) had lesions on the soles, and the remaining patient (5.6%) was an adult female who had an ASH in addition to an AMN on her right palm. Three male patients (16.6%) had a history of trauma and seven others (39%) had a history of playing football, with three of them being barefooted during playing. Eight patients (44.4%) had no remarkable history. Eleven patients (61%) used to wear thongs during their regular daily life.

The preliminary diagnoses were ASH in ten (55.6%), AMN in six (33.3%), and ALM in the remaining two (11.1%) lesions. Clinically, 17 lesions (94.4%) were on the anterior part of the sole [Figure 1]a and [Figure 2]a and the heel. The remaining lesion (5.6%) was on the right palm [Figure 3]a, [Figure 3]b. The lesions were of different sizes, shapes, and colors. Their colors were black in eight (44.4%), red-black in six (33.3%), and brown in the remaining four (22.2%) lesions. Eight lesions (44.4%) had surrounding dark dots (satellites) [Figure 2]a.
Figure 1: (a) Black macule on the volar aspect of the left big toe, (b) Dermoscopy shows red–black pigmentation with negative pseudonetwork pattern (due to cracked dried blood), a red line of blood around it and radial extensions of blood, (c and d) Positive paring test results in complete removal of pigmentation both clinically and dermoscopically.

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Figure 2: (a) Black macule on the volar aspect of the right foot, (b) Dermoscopy shows homogeneous red black pigmentation with evident parallel-ridge pattern, a red line of blood around it, extensions of blood, and red and brown globules around the main lesion as satellites, (c and d). Paring test results in complete removal of pigmentation both clinically and dermoscopically. Dermoscopy shows post-paring blood-tinged serum.

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Figure 3: (a) A black papule (thin arrow) and a melanocytic nevus (thick arrow) on the palmar aspect of the right hand, (b) The black papule has an irregular surface with a central depression (arrow), (c) Dermoscopy shows a structureless jet black lesion with a central depression showing red blood on the top (white arrow) surrounded by a collarette at the periphery (black arrow), (d-f) Paring was done by the patient's fingernail resulting in the complete removal of pigmentation both clinically and dermoscopically.

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Dermoscopically, the colors were red black in eight (44.4%), black in five (27.8%), and brown in the remaining five (27.8%) lesions. The pigmentation patterns were homogeneous (structureless) in ten (55.6%) [Figure 3]c, parallel ridge in five (27.8%) [Figure 2]b, and negative pseudonetwork in the remaining three (16.6%) lesions [Figure 1]b. Eight lesions (44.4%) had red and/or brown globules around them as satellites (globular satellites) [Figure 2]b, [Figure 2]d. Peripheral red lines with/without radial extensions were noticed around ASH in ten lesions (55.6%) [Figure 1]b and [Figure 2]b (6/6 [100%] of the clinical red-black colored lesions and 4/8 [50%] of the clinical black-colored lesions) [Table 1]. Paring performed by a dermatologist for 17 lesions (94.4%) and by the patient's fingernail for the remaining lesion (5.6%) led to complete removal of pigmentation in all lesions (100%) [Figure 1]c, [Figure 1]d, [Figure 2]c, [Figure 2]d and [Figure 3]d, [Figure 3]e, [Figure 3]f. Post-paring, blood-tinged serum was detected after removal of pigmentation in ten lesions (55.6%) was [Figure 2]d and [Table 1]. No skin biopsies were performed.
Table 1: Comparison of the frequencies of the dermoscopic findings in the current study and other studies[1],[10]

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  Discussion Top


ASH occurs predominantly in adolescents or young adults, who play sports associated with frequent quick starts, stops, and turns of the feet, such as tennis, basketball, football, and others.[11] It is most probably due to traumatic rupture of the dermal papillary capillaries, resulting in extravasation of the red blood cells into the stratum corneum.[12]

Clinically, ASH may be difficult to differentiate from ALM, AMN, pyogenic granuloma, angiokeratoma, and plantar warts.[1] Dermoscopy is a noninvasive diagnostic tool that was reported to improve the diagnostic accuracy in pigmented skin lesions.[6]

In the current study, dermoscopic examination showed that the colors were red-black in 44.4%, black in 27.8%, and brown in 27.8% of the lesions. Thus, ASH lesions have different colors, with the red-black color being the predominant one. The presence of different colors is mostly due to the differences in the durations of the lesions before presentation. These findings are consistent with the previous work of Zalaudek et al.[1] and Elmas and Akdeniz,[10] who reported different colors of ASH lesions and that the most common color was red-black in 40%[1] and 45%[10] of these studies, respectively. The other colors reported in their studies were various shades of brown to black pigmentation in 33.3% and gray to gray-black to gray-brown in 26.7%[1] and brown in 20%, red in 15%, black in 10%, brown-black in 5%, and red-brown in 5%[10] of ASH.

In the present study, the dermoscopic pigmentation patterns were homogeneous in 55.6%, followed by parallel ridge in 27.8% and negative pseudonetwork in 16.6% of lesions. In addition, globular satellites were reported in 44.4% of lesions. Thus, the homogeneous pattern was the predominant one. These data were corroborated by Zalaudek et al.,[1] who reported that the dermoscopic pigmentation patterns of ASH were homogenous in 53.3%, followed by globular in 46.7% and parallel ridge in 40% of lesions, and by Elmas and Akdeniz,[10] who found that the pigmentation patterns were homogenous in 65%, followed by globular in 55% and parallel ridge in 40% of lesions. To our knowledge, the current study was the first to demonstrate the negative pseudonetwork pattern and the red lines with/without radial extensions. The negative pseudonetwork pattern can be explained by cracking of dried blood. In a case report by Uslu et al.,[4] the negative pseudonetwork pattern was described as “intersecting connection lines”. Zalaudek et al. identified fibrillar and furrow patterns in only two patients.[1] These rare patterns were reported neither in our study nor in that of Elmas and Akdeniz.[10] The pattern of “pebbles on the ridges” reported by Saida et al.,[13] used to define multiple reddish-black pebble-like droplets with smooth margin mostly distributed on the ridges of the skin markings, was reported neither in our study nor in the studies of Zalaudek et al.[1] and Elmas and Akdeniz.[10]

On dermoscopy, early ALM often exhibits the so-called parallel ridge pattern,[14],[15] whereas AMN is characterized by the presence of parallel furrow, fibrillar, or lattice-like patterns.[14],[15],[16],[17] The presence of a parallel ridge pattern on dermoscopy has 99% specificity for detecting both melanoma in situ and invasive melanoma on acral volar skin.[18] Because of this, much care has to be exercised as to the presence of the parallel ridge pattern that was reported on dermoscopy in 20 out of 22 (91%) AML whose diagnosis was confirmed histopathologically as melanoma in situ.[19]

Paring followed by complete removal of pigmentation is a positive test. A positive paring test is a clue to the diagnosis of ASH because pigmentation in a melanocytic lesion is never limited to the stratum corneum and thus, the test is negative.[18] Paring test confirmed the diagnosis of all ASH lesions in our study and in previous studies[1],[10] and excluded that of acral melanocytic lesions, leading to avoidance of unnecessary invasive procedures. To our knowledge, the present study was the first to describe the presence of blood-tinged serum after the complete removal of pigmentation. The patient with the palm lesion detected a foreign body at the center of ASH, at the time of fingernail paring, which was the cause of the lesion.

Depending on these findings, skin biopsies were avoided in the present study, despite the preliminary diagnosis of ALM in two lesions, and in the study of Elmas and Akdeniz.[10] However, 5 out of 15 patients (33.3%) had biopsies in the study of Zalaudek et al.[1]


  Conclusion Top


It can be concluded that the clinical features of ASH may be similar to those of acral melanocytic lesions. In most cases, a precise diagnosis can be facilitated by the dermoscopic findings. The presence of a homogeneous, a negative pseudonetwork, and/or a parallel ridge pattern in addition to globular satellites, red lines with/without radial extensions around the lesions, and blood-tinged serum can achieve a great task. By these dermoscopic findings and a positive paring test, the diagnosis of ASH can be confirmed and the need for unnecessary invasive procedures can be avoided.

Acknowledgment

The authors would like to thank Dr. Robert J Pariser, Professor of Dermatology and Dermatopathology, Eastern Virginia Medical School, Norfolk, VA, USA, for his valuable touches in revising this work and sharing his valuable opinion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zalaudek I, Argenziano G, Soyer HP, Saurat JH, Braun RP. Dermoscopy of subcorneal hematoma. Dermatol Surg 2004;30:1229-32.  Back to cited text no. 1
    
2.
Sardana K, Sagar V. Black heel (talon noir) associated with a viral exanthem. Indian Pediatr 2013;50:982.  Back to cited text no. 2
    
3.
Robertson SJ, Leonard J, Chamberlain AJ. Playstation purpura. Australas J Dermatol 2010;51:220-2.  Back to cited text no. 3
    
4.
Uslu U, Heppt F, Erdmann M. Intracorneal hematoma showing clinical and dermoscopic features of acral lentiginous melanoma. Case Rep Dermatol Med 2017;2017:3509146.   Back to cited text no. 4
    
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Stolz W, Braun-O BB, Bilek P. Color Atlas of Dermatoscopy. Oxford, England: Blackwell Publishing Co.; 2002.  Back to cited text no. 5
    
6.
Argenziano G, Soyer HP, Chimenti S, Talamini R, Corona R, Sera F, et al. Dermoscopy of pigmented skin lesions: Results of a consensus meeting via the Internet. J Am Acad Dermatol 2003;48:679-93.  Back to cited text no. 6
    
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Malvehy J, Puig S. Principles of Dermoscopy. 2nd ed. Barcelona: Cege Editors; 2010.  Back to cited text no. 7
    
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Braun RP, Thomas L. Atlas of Dermoscopy. Paris: Elsevier Masson; 2007.  Back to cited text no. 8
    
9.
Thomas L, Puig S. Dermoscopy, Digital Dermoscopy and Other Diagnostic Tools in the Early Detection of Melanoma and Follow-up of High-risk Skin Cancer Patients. Acta Derm Venereol 2017;Suppl 218:14-21.  Back to cited text no. 9
    
10.
Elmas OF, Akdeniz N. Subcorneal hematoma as an imitator of acral melanoma: Dermoscopic diagnosis. North Clin Istanb 2019;7:56–9.  Back to cited text no. 10
    
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Wilkinson DS. Black heel a minor hazard of sport. Cutis 1977;20:393-6.  Back to cited text no. 11
    
12.
Urbina F, León L, Sudy E. Black heel, talon noir or calcaneal petechiae? Australas J Dermatol 2008;49:148-51.  Back to cited text no. 12
    
13.
Saida T, Koga H, Uhara H. Key points in dermoscopic differentiation between early acral melanoma and acral nevus. J Dermatol 2011;38:25-34.  Back to cited text no. 13
    
14.
Altamura D, Altobelli E, Micantonio T, Piccolo D, Fargnoli MC, Peris K. Dermoscopic patterns of acral melanocytic nevi and melanomas in a white population in central Italy. Arch Dermatol 2006;142:1123-8.  Back to cited text no. 14
    
15.
Barquet V, Dufrechou L, Nicoletti S, Acosta MA, Magliano J, Martínez M, et al. Dermoscopic patterns of 158 acral melanocytic nevi in a Latin American population. Actas Dermosifiliogr 2013;104:586-92.  Back to cited text no. 15
    
16.
Elwan NM, Eltatawy RA, Elfar NN, Elsakka OM. Dermoscopic features of acral pigmented lesions in Egyptian patients: A descriptive study. Int J Dermatol 2016;55:187-92.  Back to cited text no. 16
    
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Saida T, Oguchi S, Miyazaki A. Dermoscopy for acral pigmented skin lesions. Clin Dermatol 2002;20:279-85.  Back to cited text no. 17
    
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Ishihara Y, Saida T, Miyazaki A, Koga H, Taniguchi A, Tsuchida T, et al. Early acral melanoma in situ: Correlation between the parallel ridge pattern on dermoscopy and microscopic features. Am J Dermatopathol 2006;28:21-7.  Back to cited text no. 18
    
19.
Saida T, Miyazaki A, Oguchi S, Ishihara Y, Yamazaki Y, Murase S, et al. Significance of dermoscopic patterns in detecting malignant melanoma on acral volar skin: Results of a multicenter study in Japan. Arch Dermatol 2004;140:1233-8.  Back to cited text no. 19
    


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