The challenge of diagnosing acral lesions—those found on the palms and soles—is a familiar one for even the most seasoned dermatologists. Because these areas follow a unique set of “rules” compared to the rest of the body, clinical confidence is paramount to avoiding unnecessary biopsies while catching early-stage melanomas.
The Dermatology Digest highlights an ODAC session on the topic presented by Jennifer Stein, MD, PhD, FAAD, professor and associate vice chair at the NYU Grossman School of Medicine. The article outlines Dr. Stein’s actionable, everyday strategies, including:
- The Golden Rule: “Furrows are Fine, Ridges are Risky”
- Acquired Acral Three-Step Algorithm
- The BRAAFF Algorithm
In the article, Dr. Stein also shares some considerations in patients with darker skin types:
- Most algorithms may not perfectly translate to patients with darker skin tones.
- In Fitzpatrick Skin Types V and VI, clinicians may encounter physiologic volar melanocytic macules that display parallel ridge patterns but are entirely benign. While these findings are common in skin of color, Dr. Stein cautioned that the “index of suspicion” must remain high to ensure acral melanoma isn’t overlooked.
Evaluating the nail unit presents its own set of hurdles, as the pigment often originates in the difficult-to-biopsy nail matrix. Dr. Stein breaks down the evaluation into two categories:
- Non-melanocytic: Before suspecting a tumor, rule out fungal infections (look for a “reverse triangle” pattern) and subungual hemorrhages (look for red-to-black spots with filamentous edges).
- Melanocytic: Benign ethnic melanonychia often presents with gray, homogeneous lines. However, the “Ugly Duckling” concept is your best friend here. Look for outliers: bands that are wider at the base, involve multiple colors, or cause nail plate destruction.
Dermoscopy is an invaluable tool, but it works best when paired with clinical intuition. By mastering the distinction between furrows and ridges and remaining mindful of how these patterns shift across different skin types, clinicians can provide more accurate, confident care for their patients.
Read the original article posted to The Dermatology Digest.
