Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept 2021;11(2):e2021002 1 Dermatology Practical & Conceptual Peas Out of the Pod Theocharis N. Kirtsios1, Zoe Apalla1, Aimilios Lallas2 1 Second Department of Dermatology, Aristotle University, Thessaloniki, Greece 2 First Department of Dermatology, Aristotle University, Thessaloniki, Greece Key words: melanoma in situ, dermoscopy, diagnosis congenital nevus, acral nevus, acral melanoma Citation: Kirtsios TN, Apalla Z, Lallas A. Peas out of the pod. Dermatol Pract Concept. 2021;11(2):e2021002. DOI: https://doi .org/10.5826/dpc.1102a02 Accepted: July 22, 2020; Published: March 8, 2021 Copyright: ©2021 Kirtsios et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author: Theocharis Nektarios Kirtsios, MD, Second Department of Dermatology, Aristotle University, Thessaloniki, Greece. Email: theocharisk@hotmail.com Case Presentation A 43-year old woman presented to our department for a total-body mole check. On clinical examination, a pigmented macule was noted on her right palm (Figure 1A). The patient reported that the lesion appeared approximately 3 years earlier. Based on dermoscopic examination (Figure 1B), the lesion was assessed as suspicious for melanoma and an exci- sion was performed. The histopathological diagnosis was melanoma in situ. Teaching Point The anatomical features of acral skin produce unique and dis- tinctive dermoscopic patterns when it comes to discriminating between acral nevi and melanoma. The diagnosis is guided by inspection of the furrows and ridges. Nevi usually display a parallel furrow pattern, consisting of parallel brown lines occupying the furrows, while the ridges are not pigmented [1]. A subtype of this pattern includes brown dots in the eccrine ducts located on the ridges (“peas in the pod”). No other dis- tribution of brown dots is expected in a nevus [2]. When “the peas are out of the pod,” the suspicion of melanoma should be raised, as in our case. References 1. Saida T, Koga H. Dermoscopic patterns of acral melanocytic nevi: their variations, changes, and significance. Arch Dermatol. 2007;143(11):1423-1426. DOI: 10.1001/archderm.143.11.1423. PMID: 18025367. 2. Lallas A, Kyrgidis A, Koga H, et al. The BRAAFF checklist: a new dermoscopic algorithm for diagnosing acral melanoma. Br J Dermatol. 2015;173(4):1041-1049. DOI: 10.1111/bjd.14045. PMID: 26211689. 2 Image Letter | Dermatol Pract Concept 2021;11(2):e2021002 Figure 1. (A) A brown macule noticed on the palm of a 43-year-old woman. (B) Dermoscopy (captured with polarized dermoscopy, magnifi- cation ×10) revealed pigmentation occupying mainly the ridges and brown dots scattered all over the lesion. They were heterogeneous in size and randomly distributed, not restricted to the eccrine duct openings. The lesion was excised with the suspicion of melanoma and histopatho- logically diagnosed as melanoma in situ. (C, D) Examples of acral nevi, from different patients, displaying a “peas in a pod” pattern, with the brown dots distributed in parallel lines and equal distance between each other (polarized dermoscopy, magnification ×10).