Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(4):e2022209 1 Five Synchronous Melanomas: Role of Dermoscopy as a Triage Tool to Manage Melanoma During the COVID-19 Pandemic Carla Tubau1, Lluís Rusiñol1, Guillermo Sánchez-Rodríguez1, Helena Iznardo1, Victoria Amat-Samaranch1, Oriol Yélamos1 1 Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain Key words: COVID-19, dermoscopy, management, in situ melanoma, synchronous melanomas Citation: Tubau C, Sánchez-Rodríguez G, Iznardo H, Amat-Samaranch V, Yélamos O. Five synchronous melanomas: role of dermoscopy as a triage tool to manage melanoma during the COVID-19 pandemic. Dermatol Pract Concept. 2022;12(4):e2022209. DOI: https://doi. org/10.5826/dpc.1204a209 Accepted: January 5, 2022; Published: October 2022 Copyright: ©2022 Tubau et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: OY has received honoraria from BMS (speakers honoraria), and MSD (speakers honoraria). The other authors declare no conflicts of interest. Authorship: All authors have contributed significantly to this publication. Corresponding author: Carla Tubau, MD, Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041 Barcelona, Spain, Phone: (+34) 935537007, Fax (+34) 935537008. E-Mail: ctubau@santpau.cat Introduction Multiple meta-analyses have shown that dermoscopy is more accurate than the naked eye in melanoma diagnosis [1]. Since dermoscopy has direct histopathological cor- relates, it can be used to triage and manage pigmented le- sions [2]. Certain colors under dermoscopy such as blue over raised areas are indicators of deep melanin, whereas on flat surfaces may indicate regression [2]. Furthermore, certain structures indicate melanoma invasion such as shiny white streaks or blue-whitish veil [2]. Hence, when large lesions are challenging to be excised completely, these areas suspicious for invasion under dermoscopy such as raised blue-gray ar- eas could be sampled in order to maximize the histologic re- sults. Moreover, dermoscopy also allows the identification of small invasive melanomas thus improving its management. During our daily practice, currently in the middle of the COVID-19 pandemic, we face challenging cases that need to be managed with fewer visits than usual. Case Presentation An 89-year-old man with multiple comorbidities, ECOG 3, was referred for evaluation of a nasal pigmented lesion. Previ- ous biopsies did not reveal malignancy but he referred enlarge- ment over time. A brown-black 2.5 cm-patch with ill-defined borders covered patient’s central nasal dorsum ( Figure 1A). Dermoscopy showed asymmetric pigment around follicles, peppering, angulated lines, and areas of follicle invasion ( Figures 1, B, C and D). A complete cutaneous examination was performed identifying four further suspicious lesions. One black 2.1 x 1 cm macule on the chest (Figure  2A) showing peripheral streaks asymmetrically distributed and a central blue-whitish veil on dermoscopy ( Figure 2B). One elongated 2 Research Letter | Dermatol Pract Concept. 2022;12(4):e2022209 Figure 1. (A) Clinical image of the nasal dorsum pigmented lesion consisting of a brown-black 2.5cm patch with ill-defined borders that cov- ers the central nasal dorsum. (B-D) Dermoscopy images showing asymmetric pigmented follicular openings (arrows), angulated or polygonal lines (arrowheads), blue-gray dots or peppering (asterisk), and areas of follicle invasion (circles). Figure 2. (A) Clinical image of the 2.2 x 2 cm macule on the chest. (B) Dermoscopic image showing peripheral streaks asymmetrically dis- tributed and central blue-whitish veil. (C) Clinical image of the pigmented lesion on the neck, which presented as an elongated brown-black macule of 1.4 x 0.8 cm. (D) Dermoscopy of the neck lesion where atypical pigmented network and an irregular black blotch at the periphery can be observed. (E) Clinical image of the upper dorsum brown to black 0.5 x 0.3 cm macule. (F) Upper dorsum lesion dermoscopy showing an atypical brown network. (G) Clinical image of the pigmented lesion on the right shoulder presented as a brown-black 0.7 x 0.6 cm macule. (H) Atypical brown network and inferior-left homogeneous brown area on dermoscopy of the shoulder lesion. Research Letter | Dermatol Pract Concept. 2022;12(4):e2022209 3 brown to black 1.4 x 0.8 cm macule on the neck (Figure 2C), with an atypical pigmented network and an irregular black blotch on dermoscopy (Figure 2D). A brown to black 0.5 x 0.3  cm macule on the upper dorsum showing an atypical brown network on dermoscopy (Figures 2, E and F). Ulti- mately, a brown to black 0.7 x 0.6 cm macule on his right shoulder, with an atypical brown network and an inferior-left homogenous brown area on dermoscopy (Figures 2, G and H). Given the number of lesions suggesting melanoma and considering the patient comorbidities, a shave-excision was performed during the same initial appointment of the smaller lesions suspected to be in situ by dermoscopy (atypical net- work with absence of blue-gray color, shiny white structures or vessels): the shoulder and upper dorsum lesions. The patient was scheduled for complete excision of the chest and neck lesions, due to suspicion of invasion (blue-whit- ish veil on dermoscopy) on the former, and due to a larger size and irregular shape on the latter. Regarding the nasal lesion, although no signs of invasion were suspected, due to its large size and the potentially complex reconstruction, a dermoscopy-targeted punch biopsy was performed on the brown area, and not on the blue-gray area which may have only revealed regression. Results from histologic examination yielded four in situ melanomas, and an invasive melanoma with a 0.6 mm Breslow index (chest lesion). Wide local excision was later performed in all lesions according to the current guidelines. The patient is alive with no signs of active disease. Conclusions We present an unusual case of a man with five synchronous primary melanomas, whose management was streamlined thanks to dermoscopy. Hence, by using dermoscopy we could simplify the patient flow and minimize the number of appointments, especially useful in the current context of COVID-19 pandemic. References 1. Dinnes J, Deeks JJ, Chuchu N, et al. Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults. Cochrane Database Syst Rev. 2018;12(12):CD011902. DOI: 10.1002/14651858.CD011902. PMID: 30521682. PMCID: PMC6517096. 2. Yélamos O, Braun RP, Liopyris K, et al. Dermoscopy and derma- topathology correlates of cutaneous neoplasms. J Am Acad Der- matol. 2019;80(2):341–363. DOI: 10.1016/j.jaad.2018.07.073. PMID: 30321581.