Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(3):e2024157 1 Dermoscopy Relevance in Eyelid Lentigo Maligna Melanoma Sabina Vaccari1,2, Alice Nadia Rossi2, Matilde Roda3, Federico Cassini3, Lorenzo Maltoni2, Emi Dika1,2 1 Oncologic Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy 2 Department of Medical and Surgical sciences, DIMEC, Alma Mater Studiorum University of Bologna, Bologna, Italy 3 Unit of Ophthalmology, IRCCS Policlinico di Sant’Orsola, Department of Experimental, Diagnostic and Specialty Medicine Alma Mater Studiorum University of Bologna, Bologna, Italy Key words: dermoscopy, melanoma, periorbital skin, skin oncology Citation: Vaccari S, Rossi AN, Roda M, Cassini F, Maltoni L, Dika E. Dermoscopy Relevance in Eyelid Lentigo Maligna Melanoma. Dermatol Pract Concept. 2024;14(3):e2024157. DOI: https://doi.org/10.5826/dpc.1403a157 Accepted: February 17, 2024; Published: July 2024 Copyright: ©2024 Vaccari 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: Alice Rossi, Department of Medical and Surgical sciences, DIMEC, Alma Mater Studiorum University of Bologna, via Massarenti 9, 40138 Bologna, Italy. telephone/fax: 051 214 4844. Email: alicenadia.rossi@studio.unibo.it Introduction Lentigo maligna melanoma (LMM) is one of the most fre- quent melanomas of the head and neck region, though in represents only about 4% to 15% of melanomas. Eyelid lo- calization of LMM is extremely rare. We report three cases of eyelid LMM where dermoscopy played a key role in both the diagnosis and determination of the appropriate therapeutic course, aiming to enhance early detection of this condition. Case Presentation The first two cases involve an 84-year-old man and an 88-year-old woman, who both reported a history of a pro- gressively enlarging pigmented lesion of the lower eyelid of the right and left eye respectively. The lesion affected more than two-thirds of the lower eyelid margin and displayed an uneven pigment distribution, which did not extend be- yond the gray line (Figure 1A). The second case presented with a concomitant pigmented lesion of the left zygomatic bone area (Figure 1C). Dermoscopy displayed structureless areas, asymmetric peripheral dots and globules, a mixed brown-gray pigmentation and, in the second case, lin- ear vessels arranged perpendicularly to the eyelid margin (Figure 1, B and D). Madarosis was observed in both cases on the affected areas. An incisional biopsy was first per- formed, followed by a complete surgical excision. In the first case, a complete excision of the lesion with a limited margin of 0.5 cm was performed according to the patient consent, whereas in the second case, a complete surgical excision 2 Research Letter | Dermatol Pract Concept. 2024;14(3):e2024157 with a narrow margin was performed first, followed by a wide local excision with a margin of 0.5 cm as a second step. Reconstruction was performed with a bilateral Tripier flap in the first case and a combination of a transposition flap and a dermo-epidermal graft in the second case. Histological examination confirmed LMM, measuring 1.8 mm thickness (pT2a) in the first case, and LM in the second case. Both patients have been followed for 10 months with no evidence of recurrence. In the third case, an 84-year-old man presented with a recurrence of a melanoma on the upper rim of the eyelid, involving approximately half of it (Figure 2A). The lesion displayed two distinct areas, dermoscopically correspond- ing to an area with predominant brown-gray pigmentation and another one featuring white and red areas. Associated madarosis was also seen (Figure 2, B and C). Following an initial incisional biopsy, the excision of the lesion was per- formed with a limited margin of 0.5 cm and a conservative approach as per patient consent. Reconstruction was made with a dermo-epidermal graft. Histologic examination con- firmed LMM with a thickness of 1.8 mm (pT2a). The patient did not develop recurrences during an 18 month follow-up. He died of a cardiovascular event. Conclusions Only a limited number of palpebral rim LM/LMM cases have been documented in the literature. The palpebral rim is a unique site, representing the boundary between mucosa and skin. During standard dermatological examinations, this region is frequently disregarded and radical surgery can be challenging to perform [1,2]. Consequently, the risk of re- currence as well as the potential for ocular involvement is considerable when melanoma affects this area. Character- istic dermoscopic features involve: asymmetric follicle hy- perpigmentation, an annular-granular pattern consisting of blue-gray and brown dots and polygonal lines around and between adnexal openings leading to a gray pseudo-network. Brown-gray rhomboidal structures and homogeneous pig- mented structures with obliteration of adnexal openings are characteristic of more advanced stages. Red rhomboidal structures and whitish and red areas may also be seen [3-5]. Linear vessels may be observed as a sign of malignancy, as in basal cell carcinoma of the eyelid [5]. Madarosis, reported in all our cases, is also a critical indicator of malignancy [5,6]. Palpebral rim melanoma is a rare entity, but clinical and dermoscopic examination of this peculiar region is Figure 1. (A) Pigmented lesion affecting more than two-thirds of the lower eyelid margin of the right eye and displaying an uneven pigment distribution. Madarosis is associated. (B) Dermoscopic findings: structureless areas (red arrowheads), asymmetric peripheral dots and globules (green arrows), asym- metric perifollicular pigmentation (blue circle). (C) Pigmented lesion affecting more than two-thirds of the lower eyelid of the left eye associated to a second pigmented lesion on the left zygomatic bone area showing uneven pigment distribution. (D) Dermoscopic findings: structureless areas (red arrowheads), asymmetric peripheral dots and globules (green arrows), linear vessels arranged perpendicularly to the eyelid margin (blue arrows), asymmetric perifollicular pigmentation (blue circle). Research Letter | Dermatol Pract Concept. 2024;14(3):e2024157 3 extremely important in order to obtain an early diag- nosis and to ensure radical surgery, limiting the risk of recurrence and involvement of noble structures, such as the eye bulb. References 1. Moyer JS, Rudy S, Boonstra et al. Efficacy of Staged Excision With Permanent Section Margin Control for Cutaneous Head and Neck Melanoma. JAMA Dermatol. 2017;153(3):282-288. DOI: 10.1001/jamadermatol.2016.4603. PMID: 28002553. 2. Navarrete-Dechent C, Aleissa S, Connolly K, et al. Clinical size is a poor predictor of invasion in melanoma of the lentigo maligna type. J Am Acad Dermatol. 2021;84(5):1295-1301. DOI: 10.1016/j.jaad.2020.10.023. PMID: 33096134. PMCID: PMC8046713. 3. Tognetti L, Cartocci A, Cinotti E et al. Dermoscopy of atypi- cal pigmented lesions of the face: Variation according to facial areas. Exp Dermatol. 2023;32(12):2166-2172. DOI: 10.1111 /exd.14941. PMID: 37770421. 4. Dika E, Lambertini M, Patrizi A et al. Folliculotropism in head and neck lentigo maligna and lentigo maligna melanoma. J Dtsch Dermatol Ges. 2021 Feb;19(2):223-229. DOI: 10.1111 /ddg.14311. PMID: 33166059. 5. Cinotti E, La Rocca A, Labeille B, et al. Dermoscopy for the di- agnosis of eyelid margin tumours. Br J Dermatol. 2019;181(2): 397-398. DOI:10.1111/bjd.17743. PMID: 30729497 6. Pepe F, Roda M, Schiavi C et al. The Use of High Resolution Video- dermoscopy in Eyelid Pigmented Lesion: A Case Series. Archives of Clinical & Experimental Dermatology. 2022;4(2):1-4. Figure 2. (A) Pigmented lesion affecting about fifty percent of the upper eyelid of the left eye show- ing a dense area and a gradually shaded one, with madarosis. (B) Dermoscopic findings. Brown-gray dots (green arrows) and homogenous areas (red arrowheads). (C) Dermoscopic findings. White and red areas and peripheral brown dots (green arrows).