Thermal Injury Producing Melanoma‐Like Features on Reflectance Confocal Microscopy

ABSTRACT Objectives Reflectance confocal microscopy (RCM) improves diagnostic specificity for equivocal pigmented lesions; however, certain conditions may mimic melanoma and limit its accuracy. We aimed to characterize RCM features of thermally injured lesions that mimic melanoma. Methods We present three cases of pigmented lesions with recent thermal injury, including burn, cryotherapy, and laser exposure. Clinical, dermoscopic, and RCM findings were evaluated. Given the recent history of injury, lesions were monitored with serial follow‐up at 1, 3, and 6 months to assess evolution and guide management. Results Thermal injury produced architectural and cytological changes on RCM that mimicked melanoma, including epidermal and dermoepidermal junction disarray, pagetoid‐like cells, bright inflammatory cells, and dermal stromal alterations. These findings were observed shortly after thermal injury and were consistent across different injury types and anatomic sites. The integration of clinical history with serial follow‐up demonstrated progressive resolution of atypical features in all cases, supporting a benign etiology and allowing avoidance of biopsy. Conclusions Thermal injury is an important and reversible melanoma mimicker on RCM. Recognition of this diagnostic pitfall, combined with careful clinical correlation and short‐term follow‐up, may improve diagnostic accuracy, reduce unnecessary biopsies, and support more confident management of these lesions.