The complexity of clear cell acanthoma diagnosis
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Acanthoma clarocellulare known as clear cell acanthoma presents as a solitary, well-circumscribed red-pinkish nodule, with a diameter ranging from 5 mm to 2 cm. In most cases, it grows slowly with no subjective symptoms. The higher incidence in the legs may suggest a reactive, inflammatory nature, probably induced by stasis dermatitis. Another hypothesis indicates the derivation of acanthoma clarocellulare from the eccrine apparatus.

In dermoscopy, clear cell acanthoma has its typical and specific presentation: many linear or curvilinear glomerular vessels in the necklace-like arrangement. Only a few cases evaluated by dermoscopy showed an incomplete vascular pattern without typical linear or glomerular vessels. Zargari et al. indicate the possibility of uncommon dermoscopic features as areas of hemorrhage, orange crusts, or peripheral collarette of translucent scales. Some cases show crystalline structures or white lines. Sometimes there is a scaly surface.

Reflectance confocal microscopy is a non-invasive optical imaging technique, very useful in the diagnosis of clear cell acanthoma. There are a few typical features, such as sharp lateral circumscription or epidermal disarray related to parakeratosis. In most cases, there are large, acanthotic cells distributed over the entire surface of the lesion. Clear cell acanthoma in reflectance confocal microscopy shows dilated blood vessels expanding dermal papillae, visible even in the spinous layer of the epidermis. Sometimes inflammatory cell infiltrate is present.