Dermatology: Practical and Conceptual Letter | Dermatol Pract Concept 2021;11(2):e2021001 1 Dermatology Practical & Conceptual In Situ Melanoma of the Nipple and Areola: A Dermoscopic Report in Two New Cases Giulio Tosti1, Camilla Salvini2, Alessia Barisani3, Sabina Vaccari3 1 Divisione di Chirurgia del Melanoma, Sarcoma e Tumori Rari, IRCCS, Istituto Europeo di Oncologia, Milan, Italy 2 Unit of Dermatology, USL Toscana Centro-Prato Hospital, Prato, Italy 3 Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico Sant’Orsola-Malpighi, University of Bologna, Italy Key words: nipple, areola, melanoma, dermoscopy Citation: Tosti G, Salvini C, Barisani A, Vaccari S. In situ melanoma of the nipple and areola: a dermoscopic report in two new cases. Dermatol Pract Concept. 2021;11(2):e2021001. DOI: https://doi.org/10.5826/dpc.1102a01 Accepted: July 10, 2020; Published: March 8, 2021 Copyright: ©2021 Tosti 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: Alessia Barisani, MD, Via Massarenti 1, 40138 Bologna, Italy. Email address: alessiabarisani@gmail.com Introduction The diagnosis of nipple and areola complex (NAC) lesions can be challenging even for expert dermatologists, since sev- eral differential diagnoses, including neoplastic and inflam- matory conditions, should be acknowledged. NAC melanoma is rare; dermoscopy may aid in its correct evaluation. We report here 2 new cases of in situ NAC melanoma. Case Presentations Case 1. A 60-year-old Caucasian woman presented with a 4 mm pigmented lesion on the areola at the edge of the nipple (Figure 1A). During the previous 4 months, the lesion had progressively darkened. Dermoscopy showed a dark sym- metrical macule with a thickened atypical pigment network and irregular blotches (Figure 1B). The lesion was flat, with no signs of infiltration or discharge. Histopathology revealed an in situ melanoma. Case 2. A 48-year-old Caucasian man presented with a 7 mm irregularly shaped macule affecting his left areola (Figure 1C). He was asymptomatic and had a 100+ nevi body count. Der- moscopy showed light to darker brown pigmentation with a multi-component pattern and an atypical pigment network (Figure 1D). Also in this case histopathology revealed an in situ melanoma. B o t h p a t i e n t s u n d e r w e n t w i d e e x c i s i o n w i t h a 5-mm margin. Conclusions NAC melanoma represents an uncommon diagnosis, and until now only a few cases have been reported in the liter- ature. The first dermoscopic observation was reported by Shiga et al [1], who described a well-circumscribed, black- ish macule (10 mm in size) on the left NAC; dermoscopy displayed pigment network, irregular blotches and blue- white veil on the normal-colored NAC; and histopathology revealed a 0.3-mm melanoma. Later, Cinotti et al [2] reported another case of melanoma of the areola showing, on der- moscopy, irregular pigmented network with blotches and blue-white veil. Letter | Dermatol Pract Concept 2021;11(2):e2021001 The dermoscopic features of our 2 cases are concordant with those previously described. The differential diagnosis includes: melanocytic nevi, melanosis, and pigmented mam- mary Paget disease (MPD). Melanocytic nevi in this site often represent a challenging diagnosis, partly because of the irregular surface of the NAC, with duct orifices modifying the distribution of the pigment, thus favoring false-positive diagnoses. In a multicentric study, 16 out of the 66 nevi evaluated on dermoscopy (24%) were classified as melanoma using the 7-point checklist [2]. More- over, the normal areola can display a brown pigment network and might sometimes be a site of friction and repetitive trauma. Melanosis of the NAC can share some clinical features with melanoma, representing a possible cause of diagnostic concern. Melanosis may reveal a network and a cobblestone pattern which may be difficult to differentiate from melano- cytic lesions. Figure 1. (A) Case 1. A 60-year-old Caucasian woman presenting an atypical dark pigmented lesion 4 mm in diameter located at the areola. (B) Dermoscopy showed a dark symmetrical macule characterized by a thickened atypical pigment network and irregular blotches (B, origi- nal magnification ×20). (C) Case 2. A 48-year-old man affected by an irregularly shaped macular lesion 7 mm in diameter at the left areola. (D) Dermoscopy shows light to darker brown pigmentation with a multi-component pattern and atypical pigment network (D, original magnification ×40). Dermoscopic features of pigmented MPD include struc- tureless brown and red areas, pinkish background, irregular vessels and irregular blue and brown dots. Only a few cases of NAC melanoma with dermoscopic findings were reported in the literature. The cases presented here represent a clinico-dermoscopic report of in situ NAC melanoma. References 1. Shiga K, Oiso N, Narita T, Kimura M, Kawada A. Dermoscopy for malignant melanoma of the nipple and the areola. J Dermatol. 2015;42:339–341. DOI: 10.1111/1346-8138.12759. PMID: 25639330. 2. Cinotti E, Galluccio D, Ardigò M, et al. Nipple and areola lesions: Dermoscopy and reflectance confocal microscopy features. J Am Acad Dermatol. 2019;81(2):610-613. DOI: 10.1016/j. jaad.2018.11.017. PMID: 30458212.