Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2023;13(1):e2023033 1 Dermoscopic Features of External Ear Melanoma: A Case Series Rosario Peralta1, Horacio Cabo2, Emilia Cohen Sabban1, Gabriel Salerni3, Virginia Mariana González4 1 Dermatology Department, Instituto de Investigaciones Médicas “A. Lanari”, University of Buenos Aires, Buenos Aires, Argentina 2 Dermatology Deparment, University of Buenos Aires, Buenos Aires, Argentina 3 Dermatology Department, Hospital Provincial del Centenario de Rosario, Rosario, Argentina 4 Dermatology Department, Hospital Alemán, Buenos Aires, Argentina Key words: Melanoma, dermoscopy, ear Citation: Peralta R, Cabo H, Cohen Sabban E, Salerni G, González VM. Dermoscopic Features of External Ear Melanoma: A Case Series. Dermatol Pract Concept. 2023;13(1):e2023033. DOI: https://doi.org/10.5826/dpc.1301a33 Accepted: June 1, 2022; Published: January 2023 Copyright: ©2023 Peralta 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: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Peralta Rosario, MD, 3150 Combatientes de Malvinas, CP 1427, Ciudad Autónoma de Buenos Aires, Argentina. Tel: (+54) 011-5287-3788, Email: rosarioperalta@yahoo.com Introduction External ear melanoma (EEM) is a rare condition, corre- sponding to 1%-4% of all cutaneous melanomas. It affects mainly individuals in the sixth decade of life, being predom- inantly observed in white men, in the auricular helix. The most common subtype that have been reported is the super- ficial spreading melanoma (40.1%), followed by the lentigo maligna (33.7%) [1]. EEM usually exhibits the classical features of facial or extra-facial melanoma, both clinically and dermoscopically [2]. The majority of these melanomas are diagnosed in early stages, when the Breslow thickness is less than 2 mm, in 75% of patients [1]. We report eight clinical cases of EEM and their dermoscopic findings, diag- nosed at an early stage, emphasizing the importance of the routine clinical examination of the ears in the dermatological consultation. Case Presentation Eight patients (7 men and 1 woman) with biopsy-proven diagnosis of melanoma were analyzed. The median age was 68 years (range, 54–82 years). Two were located on the right helix, 3 on the left helix, 1 on the right lobe, 1 on the left antihelix and 1 on the left antitragus. All of them presented as a single lesion and only two patients noticed its appearance before consultation. Clinically, they were pigmented brown macules, with the exception of one that presented as a multicolored, slightly raised lesion. Most of them showed asymmetrical shape. Upon dermoscopy, in 6 out of 8 lesions, we found features of lentigo maligna, such as asymmetric pigmented follicular openings, rhomboidal structures and dark brown homogeneous areas without obliterated hair follicles (Figure1, A-F), 1 lesion presented dark brown homogeneous areas with obliterated hair fol- licles (Figure 1G) and 1 exhibited criteria for superficial 2 Research Letter | Dermatol Pract Concept. 2023;13(1):e2023033 Figure 1. Clinical and dermoscopic images of external ear melanomas. Dermoscopic examination developed. (A,B) Asymmetric pig- mented follicular openings, and concentric circles. (B) Zig-zag pattern (black arrows) and some rhomboidal structures (black asterisk). (C) Annular-granular pattern. (D,E) Rhomboidal structures. (F) Dark brown homogeneous areas without obliterated hair follicles. (G) Dark brown homogeneous areas with obliterated hair follicles. (H) Multicomponent pattern with multiple colors, atypical pigment network, neg- ative network, irregular blotches and dotted and linear irregular vessels distributed peripherally (white arrow). spreading melanoma with a multicomponent pattern with atypical pigment network, negative network, irregular blotches and atypical vessels (Figure 1H). Clinical and de- mographic data, dermoscopic findings and histopathologic result are detailed in Table 1. Conclusions In the dermoscopic findings of this EEM case series we achieved similar results to those in previous reports, show- ing classical dermoscopic features of facial and extra-facial melanomas. Research Letter | Dermatol Pract Concept. 2023;13(1):e2023033 3 Face-specific dermoscopic criteria of melanoma are asymmetric pigmented follicular openings, concentric circles, annular-granular pattern, rhomboidal structures, and homo- geneous areas. Extra facial melanoma features in general include atypical pigment network, angulated lines, irregular dots and/ or globules, irregular streaks/ pseudopods, irregu- lar blotches, regression structures, blue-white veil, negative network, shiny white structures, milky-red areas, and atyp- ical vascular pattern [3]. Concerning melanoma subtype, unlike previous reports, lentigo maligna was more frequent than superficial spreading melanoma in our series. 6 out of 8 cases were melanomas in situ, the other 2 were invasive mel- anomas (Breslow thickness 0.6 and 1.2 mm, respectively). To conclude, the importance of routine clinical examina- tion of the ears during dermatological consultations is re- inforced, recommending the use of the dermatoscope when evaluating single lesions in this location, in order to recog- nize an early melanoma. Early diagnosis of EEM directly impacts on survival and dermoscopy has been shown to aid in the correct diagnosis. References 1. Fiorio LM, Diniz LM, Spelta K, Badaró BA. Ear melanoma: a four-case series. An Bras Dermatol. 2021;96(1):64-67. DOI: 10.1016/j.abd.2020.08.003. PMID: 33281007. PMCID: PMC7838110. 2. Deinlein T, Blum A, Schulter G, et al. Clinical and Dermo- scopic Features of Melanocytic Lesions on the Face Versus the External Ear. Dermatol Pract Concept. 2021;11(4):e2021124. DOI: 10.5826/dpc.1104a124. PMID: 34631268. PMCID: PMC7838110. 3. Kittler H, Marghoob AA, Argenziano G, et al. Standardiza- tion of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy.  J Am Acad Dermatol.  2016;74(6):1093–1106. DOI:  10.1016/j.jaad.2015.12.038.  PMID: 26896294. PMCID: PMC5551974. Table 1. Clinical and demographic data, dermoscopic findings and histopathological subtype of external ear melanoma patients. Patient # Age (Years) Sex Anatomical site Single lesion (Yes/No) Dermoscopic Findings Histopathological subtype 1 57 M Right helix Yes Asymmetric pigmented follicular openings, concentric circles Lentigo maligna 2 70 F Right lobe Yes Asymmetric pigmented follicular openings, zig-zag pattern, rhomboidal structures Lentigo maligna 3 55 M Left antihelix Yes Annular-granular pattern, rhomboidal structures Lentigo maligna 4 54 M Left antitragus Yes Annular-granular pattern, rhomboidal structures, dark brown homogeneous areas without obliterated hair follicles Lentigo maligna 5 74 M Right helix Yes Gray color, annular-granular pattern, rhomboidal structures Lentigo maligna 6 73 M Left helix Yes Asymmetric pigmented follicular openings, rhomboidal structures, dark brown homogeneous areas without obliterated hair follicles Lentigo maligna 7 82 M Left helix Yes Annular-granular pattern, rhomboidal structures, dark brown homogeneous areas with obliterated hair follicles Lentigo maligna melanoma, Breslow 0,6 mm 8 65 M Right helix and auricle Yes Multicomponent pattern with atypical pigment network, negative network, irregular blotches and atypical vessels Superficial spreading melanoma, Breslow 1,2 mm