Understanding Pigmented Lesions of the Skin

by Bradley Bakotic, DPM, DO
 Podiatric and Dermatopathology
ProPath Services

Hey Doc, take a look at this. What do you think? You are half way out of the treatment room and your patient requests that you take a glance at a small pigmented lesion on the back of his leg. Is it a small junctional nevus or an early arising melanoma? Knowing the grave consequences associated with missing a melanoma, you probably don’t want to make the call after a quick inspection. Close examination, careful consideration and cutaneous biopsy are probably what is called for. 

Those of us who have been around long enough, have probably encountered an innocent enough looking lesion that turned out to be a “melanoma”. Each time you encounter this situation you probably say to yourself, I’ve got to get a bit more comfortable with these lesions. Well, here is your chance. The Podiatry profession has an excellent ambassador to the field of Dermatopathology, Dr. Bradley W. Bakotic. 

In his lecture, “Understanding Pigmented Lesions of the Skin”, Dr. Bakotic discusses malignant melanoma, melanocytic nevi, and indications for biopsy. He describes Melanoma as the great imitator because it can present as pyogenic granuloma, basal cell carcinoma, verruca vulgaris, granuloma annulare, amelanotic melanoma or a host of other cutaneous disorders. 

Melanomas are malignant neoplasms comprised of cells, which exhibit melanocytic differentiation. Not all melanomas start as large obviously malignant and invasive growths, rather they begin as small almost unperceivable lesions that evolved from only a few small cells. They have an ill-defined perimeter and the pigment is often asymmetric. Melanomas have metastatic potential when they reach the dermal level. Breslows depth and ulceration are key prognostic indicators. 

Dr. Bakotic also describes melanocytic nevi. These lesions are slightly elevated and often have dark hairs arising in them. Case presentations involving acquired nevi, congenital nevi, spitz nevi and others are reviewed. 

Dr. Bakotic reminds us that pigmented lesions of 7mm or greater on the plantar surfaces constitute an absolute indication for biopsy. 

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