CLINICAL REVIEW

Dermoscopy of pigmented skin lesions

Ralph Peter Braun, MD,
a
Harold S. Rabinovitz, MD,
b
Margaret Oliviero, ARNP, MSN,
b
Alfred W. Kopf, MD,
c
and Jean-Hilaire Saurat, MD
a
Geneva, Switzerland; Miami, Florida; and New York, New York
Dermoscopy is an in vivo method for the early diagnosis of malignant melanoma and the differential
diagnosis of pigmented lesions of the skin. It has been shown to increase diagnostic accuracy over clinical
visual inspection in the hands of experienced physicians. This article is a review of the principles of
dermoscopy as well as recent technological developments. ( J Am Acad Dermatol 2005;52:109-21.)
I
n the last two decades a rising incidence of
malignant melanoma has been observed.
1-7
Because of a lack of adequate therapies for
metastatic melanoma, the best treatment currently
is still early diagnosis and prompt surgical excision of
the primary cancer.
5,7
Dermoscopy (also known as
epiluminescence microscopy, dermatoscopy, and
amplified surface microscopy) is an in vivo method,
that has been reported to be a useful tool for the early
recognition of malignant melanoma.
8-11
The perfor-
mance of dermoscopy has been investigated by
many authors. Its use increases diagnostic accuracy
between 5% and 30% over clinical visual inspection,
depending on the type of skin lesion and experience
of the physician.
12-16
This was confirmed by recent
evidence-based publications and based on a meta-
analysis of the literature.
17,18
This article is a reviewof
the principles of dermoscopy as well as recent
technological developments.
HISTORY OF DERMOSCOPY
Skin surface microscopy started in 1663 with
Kolhaus who investigated the small vessels in the
nailfold with the help of a microscope.
11,19
In 1878,
Abbe described the use of immersion oil in light
microscopy
20
and this principle was transferred to
skin surface microscopy by the German dermatolo-
gist, Unna, in 1893.
21
He introduced the term
diascopy and described the use of immersion oil
and a glass spatula for the interpretation of lichen
planus and for the evaluation of the infiltrate in lupus
erythematosus. The term dermatoscopy was in-
troduced in 1920 by the German dermatologist
Johann Saphier who published a series of commu-
nications using a new diagnostic tool resembling
a binocular microscope with a built-in light source
for the examination of the skin.
22-25
He used this new
tool in various indications and did some interesting
morphological observations on anatomical struc-
tures of the skin which indicated the high perfor-
mance of his equipment. Skin surface microscopy
was further developed in the United States by
Goldman in the 1950s. He published a series of
interesting articles on new devices on what he called
Dermoscopy.
26-29
He was the first dermatologist to
use this new technique for the evaluation of pig-
mented skin lesions. In 1971, Rona MacKie
30
clearly
identified, for the first time, the advantage of surface
microscopy for the improvement of preoperative
diagnosis of pigmented skin lesions and for the
differential diagnosis of benign versus malignant
lesions. These investigations were continued mainly
in Europe by several Austrian and German groups.
The first Consensus Conference on Skin Surface
Microscopy was held in 1989 in Hamburg
31
and the
Consensus Netmeeting on Dermoscopy, which was
held in 2001 in Rome
32
(http://www.dermoscopy.
org), was the first international meeting of its
kind. Today dermoscopy has become a routine
technique in Europe and is gaining acceptance in
other countries.
From the Pigmented Skin Lesion Unit, Department of Dermatol-
ogy, University Hospital Geneva
a
; Skin and Cancer Associates,
Plantation, Fla, and Department of Dermatology, University of
Miami School of Medicine
b
; and The Ronald O. Perelman
Department of Dermatology, New York University School of
Medicine.
c
Funding sources: The work of Dr Braun has been supported by the
Swiss Cancer League. Dr Kopf has the following funding
sources: The Ronald O. Perelman Department of Dermatology,
New York University School of Medicine, Joseph H. Hazen
Foundation, Mary and Emanuel Rosenthal Foundation, Kaplan
Comprehensive Cancer Center (Cancer Center Support Core
Grant No. 5P30-CA-16087), Blair O. Rogers Medical Research
Fund, The Rahr Family Foundation, and Stravros S. Niarchos
Foundation Fund of the Skin Cancer Foundation.
Conflict of interest: None.
Accepted for publication November 9, 2001.
Reprint requests: R. P. Braun, MD, Department of Dermatology,
University Hospital Geneva, 24, rue Micheli-du-Crest, CH
1211Geneva 14, Switzerland. E-mail: braun@melanoma.ch.
0190-9622/$30.00
2005 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2001.11.001
109
PHYSICAL ASPECTS
Light is either reected, dispersed, or absorbed by
the stratum corneum because of its refraction index
and its optical density, which is different from air.
33
Thus, deeper underlying structures cannot be ade-
quately visualized. However, when various immer-
sion liquids are used, they render the skin surface
translucent and reduce the reflection, so that un-
derlying structures are readily visible. The applica-
tion of a glass plate flattens the skin surface and
provides an even surface. Optical magnification is
used for examination. Taken together, these optical
means allow the visualization of certain epidermal,
dermo-epidermal, and dermal structures.
MATERIAL FOR DERMOSCOPY
Dermoscopy requires optical magnication and
liquid immersion. This can be performed with very
simple, inexpensive equipment.
34,35
Specially de-
signed handheld devices with 10 to 20 times magni-
fication are commercially available (Dermatoscope
[Heine AG]; DermoGenius Basic [Rodenstock
Prazisionsoptik]; Episcope [Welch-Allyn]; DermLite
[3Gen, LLC]). Photographic documentation can be
performed with a dermoscopic attachment to a stan-
dard camera (Dermaphot, Heine, AG) which can be
used also with some digital cameras. Most recently,
digital cameras have been designed that are attached
to computers. This allows easy storage, retrieval, and
follow-up of pigmented skin lesions. For dermatol-
ogists with less experience in dermoscopy, some of
the systems may offer the possibility of computer-
assisted diagnosis for malignant melanoma or for
consulting an expert through telemedicine.
DERMOSCOPIC CRITERIA
Colors
The use of dermoscopy allows the identication
of many different structures and colors, not seen by
the naked eye.
Colors play an important role in dermoscopy.
Common colors are light brown, dark brown, black,
blue, blue-gray, red, yellow, and white. The most
important chromophore in melanocytic neoplasms is
melanin.
11,13,36
The color of melanin essentially
depends on its localization in the skin. The color
black is due to melanin located in the stratum
corneum and the upper epidermis, light to dark
brown in the epidermis, gray to gray-blue in the
papillary dermis and steel-blue in the reticular
dermis.
11,13
The color blue occurs when there is
melanin localized within the deeper parts of the skin
because the portions of visible light with shorter
wavelengths (blue-violet end of spectrum) are more
dispersed than portions with longer wavelengths
(red end of visible spectrum).
37,38
The color red is
associated with an increased number or dilatation of
blood vessels, trauma, or neovascularization. The
color white is often caused by regression and/or
scarring.
11
Dermoscopic structures
In this context we will use the nomenclature as
proposed by the recent Consensus Netmeeting (held
in Rome in 2001) with some revisions
32
:
Pigment network. The pigment network is
a grid-like (honeycomb-like) network consisting
of pigmented lines and hypopigmented
holes.
11,13,36,37,39
The anatomic basis of the
Table I. Vascular architecture of pigmented skin lesions according to Kreusch and Koch
57
Morphological aspect Type of pathology
Tree-like vessels Thick, arborizing vessels, superficial Pigmented BCC of any type (discrete in
superficial BCCs)
Corona vessels Surround the tumor Sebaceous gland hyperplasia
Thinner than tree-like vessels
Less curved than tree-like vessels
Comma-shaped vessels Short, strong, curved, Dermal nevi
Located on the tumor
Short distance, parallel to skin surface
Point vessels Short capillary loops Thin malignant melanomas
Dense packed red points Epithelial tumors such as actinic keratosis,
Bowens disease, etc (short vertical height) Not in the holes of the pigment network
Hairpin vessels Long capillary loops of thicker tumors at the
border
Thick melanomas
Whitish halo in tumors with keratin SCC keratoacanthoma, seborrheic keratosis
BCC, Basal cell carcinoma; SCC, squamous cell carcinoma.
J AM ACAD DERMATOL
JANUARY 2005
110 Braun et al
pigment network is either melanin pigment in
keratinocytes, or in melanocytes along the dermoe-
pidermal junction.
40
The reticulation (network) rep-
resents the rete ridge pattern of the epidermis.
41-43
The relatively hypomelanotic holes in the network
correspond to tips of the dermal papillae and the
overlying suprapapillary plates of the epider-
mis.
13,36,37
The pigment network can be either typical or
atypical. A typical network is relatively uniform,
regularly meshed, homogeneous in color, and usu-
ally thinning out at the periphery.
36,39,44
An atypical
network is nonuniform, with darker and/or broad-
ened lines and holes that are heterogeneous in
area and shape. The lines are often hyperpigmented
and may end abruptly at the periphery.
36,39,44
If the rete ridges are short or less pigmented, the
pigment network may not be visible. Areas devoid of
any network (but without signs of regression) are
called structureless areas.
11,45
Dots. Dots are small, round structures less than
0.1 mm in diameter, which may be black, brown,
gray, or blue-gray.
11,13,32,36
Black dots are caused by
pigment accumulation in the stratumcorneumand in
the upper part of the epidermis.
11,37,42,46
Brown dots
represent focal melanin accumulations at the der-
moepidermal junction.
47
Gray-blue granules (pep-
pering) are caused by tiny melanin structures in the
papillary dermis. Gray-blue or blue granules are due
to loose melanin, fine melanin particles or melanin
dust in melanophages or free in the deep papillary
or reticular dermis.
11,37,42,46
Globules. Globules are symmetrical, round to
oval, well-demarcated structures that may be brown,
black, or red.
11,13,32,36
They have a diameter which is
usually larger than 0.1 mm and correspond to nests
of pigmented benign or malignant melanocytes,
clumps of melanin, and/or melanophages situated
usually in the lower epidermis, at the dermoepider-
mal junction, or in the papillary dermis.
11,37,42,46
Both dots and globules may occur in benign as
well as in malignant melanocytic proliferations. In
benign lesions, they are rather regular in size and
shape and quite evenly distributed (frequently in the
center of a lesion).
32,36
In melanomas they tend to
vary in size and shape and are frequently found in
the periphery of lesions.
32,36,48
Branched streaks. Branched streaks are an
expressionof analteredpigmentednetworkinwhich
the network becomes disrupted or broken up.
11,32,45
Their pathological correlations are remnants of pig-
mented rete ridges and bridging nests of melanocytic
cells within the epidermis and papillary dermis.
11
Radial streaming. Radial streaming appears as
radially and asymmetrically arranged, parallel linear
extensions at the periphery of a lesion.
13,49
Histo-
logically, they represent confluent pigmented junc-
tional nests of pigmented melanocytes.
13,36
Pseudopods. Pseudopods represent ngerlike
projections of dark pigment (brown to black) at the
periphery of the lesion.
13,49,50
They may have small
knobs at their tips, and are either connected to the
pigment network or directly connected to the tumor
body.
13,50
They correspond as well to intraepidermal
or junctional confluent radial nests of melano-
cytes.
13,50
Menzies et al
49
found pseudopods to be
one of the most specific features of superficial
spreading melanoma.
Streaks. Streaks is a term used by some
authors interchangeably with radial streaming or
Fig 2. Algorithm for the determination of melanocytic
versus nonmelanocytic lesions according to the proposi-
tion of the Board of the Consensus Netmeeting. Adapted
from Argenziano G et al. J Am Acad Dermatol 2003;48:
679-93.
32
Fig 1. Two-step procedure for the classication of pig-
mented skin lesions. Adapted from Argenziano G et al.
J Am Acad Dermatol 2003;48:679-93.
32
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al 111
Fig 3. A, Macroscopic picture of a superficial spreading malignant melanoma (Breslow
thickness 0.52 mm; Clark level II). B, Dermoscopy of A shows (atypical) pigment network and
branched streaks and can therefore be considered a melanocytic lesion.
Fig 4. A, Macroscopic picture of a blue nevus. B, Dermoscopy of A shows steel-blue areas (no
pigment network, no aggregated globules, no branched streaks).
Fig 6. A, Macroscopic picture of a seborrheic keratosis. B, Dermoscopy of A shows comedo-
like openings and multiple milia-like cysts.
Fig 5. A, Macroscopic picture of a seborrheic keratosis. B, Dermoscopy of A shows comedo-
like openings (a), multiple milia-like cysts (b), and fissures (c).
J AM ACAD DERMATOL
JANUARY 2005
112 Braun et al
pseudopods. This is because both these structures
have the same histopathological correlation.
11,37,42,46
Streaks can be irregular, when they are unevenly
distributed (malignant melanoma), or regular (sym-
metrical radial arrangement over the entire lesion).
The latter is particularly found in the pigmented
spindle cell nevi (Reeds nevi).
51-53
Structureless areas. Structureless areas repre-
sent areas devoid of any discernible structures (eg,
globules, network). They tend to be hypopig-
mented, which is due to the absence of pigment or
diminution of pigment intensity within a pigmented
skin lesion.
11
Blotches. A blotch (also called black lamella by
some authors) is caused by a large concentration of
melanin pigment localized throughout the epidermis
and/or dermis visually obscuring the underlying
structures.
41-43,46
Regression pattern. Regression appears as
white scar-like depigmentation (lighter than the sur-
rounding skin) or peppering (speckled multiple
blue-gray granules within a hypopigmented area).
Histologically, regression shows brosis, loss of pig-
mentation, epidermal thinning, effacement of the rete
ridges, and melanin granules free in the dermis or in
melanophages scattered in the papillary dermis.
43,46
Blue-white veil. Blue-white veil is an irregu-
lar, indistinct, conuent blue pigmentation with
an overlying white, ground-glass haze.
13,32
The
pigmentation cannot occupy the entire lesion.
Fig 8. A, Macroscopic picture of a basal cell carcinoma. B, Dermoscopy of A shows multiple
spoke wheel areas.
Fig 7. A, Macroscopic picture of a basal cell carcinoma. B, Dermoscopy of A shows maple
leafelike areas, ovoid nests, and arborized telangiectasia.
Fig 9. A, Macroscopic picture of an angioma. B, Dermoscopy of A shows red lagoons.
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al 113
Histopathologically this corresponds to an aggrega-
tion of heavily pigmented cells or melanin in the
dermis (blue color) in combination with a compact
orthokeratosis.
13,32,36,43,46,54
Vascular pattern. Pigmented skin lesions may
have dermoscopically visible vascular patterns,
which include comma vessels, point vessels,
tree-like vessels, wreath-like vessels, and hair-
pin-like vessels (Table I).
55-57
Atypical vascular
patterns may include linear, dotted, or globular red
structures irregularly distributed within the le-
sion.
32,36,58,59
Some of the vascular patterns may be
caused by neovascularization. For the evaluation of
vascular patterns, there has to be as little pressure as
possible on the lesion during examination because
otherwise the vessels are simply compressed and
will not be visible. The use of ultrasound gel for
immersion helps to reduce the pressure necessary
for the best evaluation of the skin lesion.
57
Milia-like cysts. Milia-like cysts are round whit-
ish or yellowish structures which are mainly seen in
seborrheic keratosis.* They correspond to intraepi-
dermal keratin-lled cysts and may also be seen in
congenital nevi as well as in some papillomatous
melanocytic nevi. At times, milia-like cysts are
pigmented, and thus, can resemble globules.
*References 8, 11, 13, 32, 36, 37, 49, 55, 60-63.
Comedo-like openings (crypts, pseudofollic-
ular openings). Comedo-like openings (with
blackhead-like plugs) are mainly seen in sebor-
rheic keratoses or in some rare cases in papilloma-
tous melanocytic nevi.
y
The keratin-filled invaginations
of the epidermis correspond to the comedo-like
structures histopathologically.
y
References 8, 11, 13, 32, 36, 37, 49, 55, 60-64.
Fissures and ridges (brain-like appear-
ance). Fissures are irregular, linear keratin-lled
depressions, commonly seen in seborrheic kerato-
ses.
63
They may also be seen in melanocytic nevi
with congenital patterns and in some dermal mela-
nocytic nevi. Multiple fissures might give a brain-
like appearance to the lesion.
32,36,63,65
This pattern
has also been named gyri and sulci or mountain
and valley pattern by some authors.
11
Fingerprint-like structures. Some at sebor-
rheic keratoses (also known as solar lentigines) can
show tiny ridges running parallel and producing
a pattern that resembles ngerprints.
11,32,65,66
Moth-eaten border. Some at seborrheic kera-
toses (mainly on the face) have a concave border
so that the pigment ends with a curved structure,
which has been compared to a moth-eaten gar-
ment.
11,13,32,63,65,66
Leaf-like areas. Leaf-like areas (maple leafelike
areas) are seen as brown to gray-blue discrete
bulbous blobs, sometimes forming a leaf-like pat-
tern.* Their distribution reminds one of the shape
of nger pads. In absence of a pigment network,
they are suggestive of pigmented basal cell car-
cinoma.
11,32,67
*References 8, 9, 11, 13, 32, 36, 37, 39, 55, 65,
67, 68.
Spoke wheelelike structures. Spoke wheele
like structures are well-circumscribed, brown to
gray-blue-brown, radial projections meeting at
a darker brown central hub.
11,32,67
In the absence
of a pigment network, they are highly suggestive of
basal cell carcinoma.
Table II. Pattern analysis according to Pehamberger et al
39
(modified)
Lentigo simplex Junctional nevus Compound nevus Dermal nevus Blue nevus
Regular pigment
network without
interruptions
Regular pigment
network without
interruptions
Regular pigment
network without
interruptions
No criteria for
melanocytic lesion
Steel-blue areas
Regular border, thins
out at periphery
Regular border, thins
out at periphery
Regular border, thins
out at periphery
No pigment network No pigment network
Black dots over grids
of pigment
network
Heterogeneous holes
of pigment
network
Heterogeneous holes
of pigment
network
Brown globules lll-defined
Brown-black globules
at center of the
lesion
Brown globules Brown globules Homogeneous
colors
White veils are
possible
Homogeneous colors Homogeneous colors Symmetric papular
appearance
Pseudonetwork No pseudonetwork
All criteria for
melanocytic lesion
possible
Comma-shaped
blood vessels
Color heterogeneity
possible
J AM ACAD DERMATOL
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114 Braun et al
Large blue-gray ovoid nests. Ovoid nests are
large, well-circumscribed, conuent or near-con-
uent, pigmented ovoid areas, larger than glob-
ules, and not intimately connected to a pigmented
tumor body.
11,32,67
When a network is absent,
ovoid nests are highly suggestive of basal cell
carcinoma.
Multiple blue-gray globules. Multiple blue-
gray globules are round, well-circumscribed struc-
tures that are, in the absence of a pigment network,
highly suggestive of basal cell carcinoma.
11,32,67
They have to be differentiated from multiple blue-
gray dots (which correspond to melanophages and
melanin dust).
Table III. ABCD rule of dermoscopy according to Stoiz et al (modified)
11,45
Points Weight factor Subscore range
Asymmetry Complete symmetry 0 1.3 0-2.6
Asymmetry in 1 axis 1
Asymmetry in 2 axis 2
Border 8 segments, 1 point for abrupt cut-off of pigment 0-8 0.1 0-0.8
Color 1 point for each color: 1-6 0.5 0.5-3.0
White
Red
Light brown
Dark brown
Black
Blue-gray
Differential structures 1 point for every structure: 1-5 0.5 0.5-2.5
Pigment network
Structureless areas
Dots
Globules
Streaks
Total score range: 1.0-8.9
Table II. Contd
Malignant melanoma Atypical (Clark) nevus Angioma Seborrheic keratosis Pigmented BCC
Heterogeneous
(colors and
structures)
Irregular pigment
network with
interruptions
No features of
melanocytic lesion
No features for
melanocytic lesion
No features for
melanocytic lesion
Asymmetry (colors
and structures)
Heterogeneous holes No pigment network Pigment network
usually absent
Maple-leafelike
pigmentation
Irregular pigment
network
Irregular border Red, red-blue, or
red-black lagoons,
( globules, saccules)
Milia-like cysts Telangiectasia
Irregular border with
abrupt peripheral
margin
Heterogeneity of
colors
Abrupt border cut-off Pseudofollicular
openings,
comedo-like
openings (plugs)
Tree-like blood
vessels
Structureless areas Gray-white veil Rough surface Dirty gray-brown to
gray-black colors
Gray-blue or red-rose
veils
Absence of primary
criteria for
malignant
melanoma
Abrupt border cut-off
Red Opaque gray-brown
colors
Pseudopods/radial
streaming
Point and hairpin
vessels
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Braun et al 115
DIFFERENTIAL DIAGNOSIS OF
PIGMENTED LESIONS OF THE SKIN
There are many publications on the subject of the
differential diagnosis of pigmented lesions of the
skin. The 5 algorithms most commonly used are
pattern analysis
8,39,62
; the ABCD rule of dermo-
scopy
11,45,70
; the 7-point checklist
32,36,44
; the
Menzies method
13,32,49
; and the revised pattern
analysis.
71
The Board of the Consensus Netmeeting agreed
on a two-step procedure for the classication of
pigmented lesions of the skin (Fig 1). A similar
approach has been proposed by other authors in
the past.
The rst step is the differentiation between
a melanocytic and a nonmelanocytic lesion. For
this decision, the algorithm in Fig 2 is used.
Are aggregated globules, pigment network,
branched streaks (Fig 3), homogeneous blue pig-
mentation (blue nevus: Fig 4), or a parallel pattern
(palms, soles, and mucosa) visible? If this is the case,
the lesion should be considered as a melanocytic
lesion (Fig 3). If not, the lesion should be evaluated
for the presence of comedo-like plugs, multiple
milia-like cysts, and comedo-like openings, irregular
crypts, light brown fingerprint-like structures, or
fissures and ridges (brain-like appearance) pat-
tern. If so, the lesion is suggestive of a seborrheic
keratosis (Figs 5 and 6). If not, the lesion has to be
evaluated for the presence of arborizing blood
vessels (telangiectasia), leaf-like areas, large blue-
gray ovoid nests, multiple blue-gray globules, spoke
wheel areas, or ulceration. If present, the lesion is
suggestive of basal cell carcinoma (Figs 7 and 8). If
not, one has to look for red or red-blue (to black)
lagoons. If these structures are present, the lesion
should be considered a hemangioma (Fig 9) or an
angiokeratoma. If all the preceding questions were
answered with no, the lesion should still be
considered to be a melanocytic lesion.
Once the lesion is identied to be of melanocytic
origin, the decision has to be made if the melanocytic
lesion is benign, suspect, or malignant. To accom-
plish this, 4 different approaches are the most
commonly used.
Pattern analysis (Pehamberger et al)
Pattern recognition has historically been used by
clinicians and histopathologists to differentiate be-
nign lesions from malignant neoplasms. A similar
process has been found useful with dermoscopy,
and has been termed pattern analysis. It allows
distinction between benign and malignant growth
features. It was described by Pehamberger and
colleagues based on the analysis of more than 7000
pigmented skin lesions.
8,39,62
Table II shows the
typical patterns of some common, pigmented skin
lesions using pattern analysis.
ABCD rule of dermatoscopy (Stolz et al)
The ABCD rule of dermatoscopy, described by
Stolz et al in 1993 was based on an analysis of 157
pigmented skin lesions.
11,70
The complete ABCD
rule is explained in Table III.
For the evaluation of asymmetry, the lesion is
divided into 4 segments (2 perpendicular axes). The
axes are oriented so that the lowest asymmetry is
obtained. For asymmetry in both axes, a value of 2 is
obtained. To calculate the subscore, the value of each
ABCD category has to be multiplied by the corre-
sponding weight factor. To obtain the total score
value, the different ABCD subscores have to be
added.
The total score ranges from 1 to 8.9. A lesion with
a total score greater than 5.45 should be considered
as melanoma. A lesion with a total score of 4.75
or less can be considered as benign. A lesion with
a score value between 4.75 and 5.45 should be
Table IV. The 7-point checklist according to
Argenziano et al
44
Criteria 7-point score
Major criteria
Atypical pigment network 2
Blue-white veil 2
Atypical vascular pattern 2
Minor criteria
Irregular streaks 1
Irregular pigmentation 1
Irregular dots/globules 1
Regression structures 1
Table V. The Menzies Method according to
Menzies et al
13,49
Negative features
Point and axial symmetry of pigmentation
Presence of a single color
Positive features
Blue-white veil
Multiple brown dots
Pseudopods
Radial streaming
Scar-like depigmentation
Peripheral black dots-globules
Multiple colors (5 or 6)
Multiple blue/gray dots
Broadened network
J AM ACAD DERMATOL
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116 Braun et al
considered suspicious and should therefore be
monitored closely or removed.
11,70
7-point checklist
In 1998 Argenziano and colleagues described a 7-
point checklist based on the analysis of 342 pig-
mented skin lesions.
32,36,44
They distinguish 3 major
criteria and 4 minor criteria (Table IV). Each major
criterion has a score of 2 points while each minor
criterion has a score of 1 point. A minimum total
score of 3 is required for the diagnosis of malignant
melanoma.
Menzies method
In the Menzies method
13,32,49
for diagnosing
melanoma, both of the following negative features
must not be found: a single color (tan, dark brown,
gray, black, blue, and red, but white is not consid-
ered) and point and axial symmetry of pigmenta-
tion (refers to pattern symmetry around any axis
through the center of the lesion). This does not
require the lesion to have symmetry of shape.
Additionally, at least one positive feature must be
found (Table V).
Exceptions to the algorithms
The ABCD rule is not applicable for pigmented
lesions on the palms, soles, or face.
11
Palms and soles
have a particular anatomy which is characterized by
marked orthokeratosis and the presence of sulci and
gyri. The sweat ducts join the surface at the summits
of the gyri.
11,32
A classification of 10 different
dermoscopy patterns on the palms and soles has
been proposed by Saida et al.
72
The face has a very particular anatomic architec-
ture especially concerning the dermoepidermal
junction where rete ridges are shorter. That is why
facial lesions often do not exhibit a regular pigment
network. Dermoscopy shows a broadened pigment
reticulation which is called a pseudonetwork. This
does not correspond to the projection of pigmented
rete ridges. It is due to a homogeneous pigmentation
which is interrupted by the surface openings of the
adnexal structures.
11,66,73
The differential diagnosis of a pseudonetwork is
solar lentigo, seborrheic keratosis, lentigo simplex,
melanoma in situ, lichen planuselike keratosis, and
pigmented actinic keratosis.
11,66,73
These lesions
are often difficult to distinguish dermoscopically.
However, when there are multiple colors and
a broadened, thickened, and irregular pseudonet-
work, melanoma is often the diagnosis suggested.
Other, more specific characteristics include an an-
nular granular or rhomboidal pattern.
11,66,73
Revised pattern analysis
The overall general appearance of color, architec-
tural order, symmetry of pattern, and homogeneity
(CASH) are important components in distinguishing
these two groups. Benign melanocytic lesions tend
to have few colors, architectural order, symmetry of
pattern, or homogeneity. Malignant melanoma often
has many colors and much architectural disorder,
asymmetry of pattern, and heterogeneity.
The reticular pattern or network pattern is the
most common global feature in melanocytic lesions.
This pattern represents the junctional component
Table VI. Pattern of benign and malignant lesions
Benign Malignant
Dots Centrally located or situated right on the
network
Unevenly distributed and scattered focally at
the periphery
Globules Uniform in size, shape, and color, symmetrically
located at the periphery, centrally located, or
uniform throughout the lesion as in a
cobblestone pattern
Globules that are unevenly distributed and
when reddish are highly suggestive of
melanoma
Streaks Radial streaming or pseudopods tend to be
symmetrical and uniform at the periphery
Radial streaming or pseudopods tend to be
focal and irregular at periphery
Blue-white veil Tends to be centrally located Tends to be asymmetrically located or diffuse
almost over entire lesion
Blotch Centrally located or may be diffuse
hyperpigmented area that extends almost to
periphery of the lesion
Asymmetrically located or there are often
multiple asymmetrical blotches
Network Typical network that consists of light to dark
uniform pigmented lines and
hypopigmented holes
Atypical network that may be nonuniform with
black/brown or gray thickened lines and
holes of different sizes and shapes
Network borders Either fades into the periphery or is
symmetrically sharp
Focally sharp
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al 117
of a melanocytic nevus (Clark nevus, dysplastic
nevus).
32,36,71
Another pattern is the so-called globular pattern.
It is characterized by the presence of numerous
aggregated globules. This pattern is commonly
seen in a congenital nevus, superficial type.
32,36,71
The cobblestone pattern is very similar to the
globular pattern but is composed of closer aggre-
gated globules, which are somehow angulated, re-
sembling cobblestones.
The homogeneous pattern appears as diffuse
pigmentation, which might be brown, gray-blue,
gray-black, or reddish black.
32,36,71
No pigment
network or any other distinctive dermoscopy struc-
ture is found. An example is the homogeneous steel-
blue color seen in blue nevi.
The so-called starburst pattern is characterized by
the presence of streaks in a radial arrangement,
which is visible at the periphery of the lesion.
32,36,71
This pattern is commonly seen in Reed nevi or Spitz
nevi.
The parallel pattern is exclusively found on the
palms and soles due to the particular anatomy of
these areas.
32,36,71
The combination of 3 or more distinctive dermo-
scopic structures (ie, network, dots, and globules as
well diffuse areas of hyperpigmentation and hypo-
pigmentation) within a given lesion is called multi-
component pattern.
32,36,71
This pattern is highly
suggestive of melanoma, but might be observed in
some cases in acquired melanocytic nevi and con-
genital nevi.
The term lesions with indeterminate patterns
are dermoscopic patterns that can be seen in both
benign and malignant pigmented lesions. Clinically
and dermoscopically, one cannot make a distinction
between whether they are melanomas or atypical
nevi.
In addition to the global features already men-
tioned, the local features (dermoscopic structures
such as the pigment network, dots, and globules, etc)
are important to evaluate melanocytic lesions
(Table VI).
PERSPECTIVES
Because computer hardware has become user-
friendly and more affordable, digital dermoscopy
will become more integrated into the clinical setting.
The currently available digital dermoscopic systems
already have an acceptable picture quality which
comes close to a photograph.
74
Digital images offer
the possibility of computer storage and retrieval of
dermoscopic images and patient data.
48,75-78
Some
systems even offer the potential of computer-
assisted diagnosis.
79-94
Because diagnostic accuracy
with dermoscopy has been shown to depend on the
experience of the dermatologist, such objective
systems might help less-experienced dermatologists
in the future.
Another expanding eld is teledermoscopy. At
the beginning of the digital dermoscopic era, tele-
dermoscopy was used between experts to exchange
difcult or interesting images. The development of
new electronic media and the evolution of the
Internet will have an important impact as the in-
frastructure becomes available to almost everyone,
and the exchange is now easy to perform. Recent
studies were able to show the feasibility and impor-
tance of teledermoscopy.
95-98
This was recently used
in a Consensus Netmeeting on Dermoscopy held in
Rome during the first World
57,69
Congress on Der-
moscopy (http://www.dermoscopy.org).
32
We thank Dr G. Argenziano, Dr J. Kreusch, Professor S.
Menzies, Professor H. Pehamberger, and Professor W.
Stolz for their suggestions and their permission for the
reproductions. We also thank Dr S. Rabinovitz for her help
during the entire editing process and for her valuable
suggestions.
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