Dermoscopic evaluation of skin lesions
- Ashfaq A Marghoob, MD
Ashfaq A Marghoob, MD
- Attending Physician
- Memorial Sloan-Kettering Cancer Center
- Natalia Jaimes, MD
Natalia Jaimes, MD
- Assistant Professor
- Miller School of Medicine, University of Miami
Dermoscopy is a noninvasive, in vivo technique primarily used for the examination of pigmented skin lesions; however, it can also assist clinicians in assessing amelanotic lesions. Dermatoscopy, epiluminescence microscopy, incident light microscopy, and skin-surface microscopy are synonyms. Dermoscopy is performed with a handheld instrument called a dermatoscope. The procedure allows for the visualization of subsurface skin structures in the epidermis, dermoepidermal junction, and superficial dermis; these structures are not visible to the naked eye [1-3].
Dermoscopic diagnosis involves the recognition of specific structures, or their absence, to rule out or confirm a given diagnosis. From a cognitive perspective, this task may be accomplished using a bottom-up or a top-down strategy. In the bottom-up approach, the observer performs a visual search for salient details (individual features) to arrive at a diagnosis, whereas in the top-down strategy the observer recognizes the general context, generates a hypothesis of the likely clinical diagnosis, and performs a targeted dermoscopic search for specific features to confirm the presumed clinical diagnosis .
This topic will review several algorithms and scoring systems that use mainly a top-down strategy to help clinicians distinguish melanocytic lesions from nonmelanocytic lesions (First Step) and differentiate benign melanocytic lesions from suspicious or malignant lesions (Second Step). The general principles of dermoscopy, dermoscopic structure terminology, dermoscopic evaluation of skin lesions, and the dermoscopic evaluation of facial, mucosal, and acral volar skin lesions are discussed separately. Dermoscopy of nail pigmentation and dermoscopic algorithms for skin cancer triage are also discussed separately.
●(See "Overview of dermoscopy".)
●(See "Dermoscopy of facial lesions".)
- Marghoob AA, Swindle LD, Moricz CZ, et al. Instruments and new technologies for the in vivo diagnosis of melanoma. J Am Acad Dermatol 2003; 49:777.
- Menzies SW, Ingvar C, McCarthy WH. A sensitivity and specificity analysis of the surface microscopy features of invasive melanoma. Melanoma Res 1996; 6:55.
- Argenziano G, Soyer HP. Dermoscopy of pigmented skin lesions--a valuable tool for early diagnosis of melanoma. Lancet Oncol 2001; 2:443.
- Wolfe JM, Butcher SJ, Lee C, Hyle M. Changing your mind: on the contributions of top-down and bottom-up guidance in visual search for feature singletons. J Exp Psychol Hum Percept Perform 2003; 29:483.
- Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol 2003; 48:679.
- Marghoob AA, Braun R. Proposal for a revised 2-step algorithm for the classification of lesions of the skin using dermoscopy. Arch Dermatol 2010; 146:426.
- Blum A, Clemens J, Argenziano G. Modified dermoscopic algorithm for the differentiation between melanocytic and nonmelanocytic skin tumors. J Cutan Med Surg 2006; 10:73.
- Stolz W, Riemann, A Cognetta AB, et al. ABCD rule of dermoscopy: a new practical method for early recognition of maligant melanoma. Eur J Dermatol 1994; 4:521.
- Pehamberger H, Steiner A, Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions. I. Pattern analysis of pigmented skin lesions. J Am Acad Dermatol 1987; 17:571.
- Argenziano G, Fabbrocini G, Carli P, et al. Epiluminescence microscopy for the diagnosis of doubtful melanocytic skin lesions. Comparison of the ABCD rule of dermatoscopy and a new 7-point checklist based on pattern analysis. Arch Dermatol 1998; 134:1563.
- Henning JS, Dusza SW, Wang SQ, et al. The CASH (color, architecture, symmetry, and homogeneity) algorithm for dermoscopy. J Am Acad Dermatol 2007; 56:45.
- Soyer HP, Argenziano G, Zalaudek I, et al. Three-point checklist of dermoscopy. A new screening method for early detection of melanoma. Dermatology 2004; 208:27.
- Malvehy J, Puig S, Argenziano G, et al. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol 2007; 57:84.
- Zaballos P, Puig S, Llambrich A, Malvehy J. Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol 2008; 144:75.
- Agero AL, Taliercio S, Dusza SW, et al. Conventional and polarized dermoscopy features of dermatofibroma. Arch Dermatol 2006; 142:1431.
- Menzies SW, Westerhoff K, Rabinovitz H, et al. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000; 136:1012.
- Navarrete-Dechent C, Bajaj S, Marchetti MA, et al. Association of Shiny White Blotches and Strands With Nonpigmented Basal Cell Carcinoma: Evaluation of an Additional Dermoscopic Diagnostic Criterion. JAMA Dermatol 2016; 152:546.
- Zalaudek I, Giacomel J, Schmid K, et al. Dermatoscopy of facial actinic keratosis, intraepidermal carcinoma, and invasive squamous cell carcinoma: a progression model. J Am Acad Dermatol 2012; 66:589.
- Jaimes N, Zalaudek I, Braun RP, et al. Pearls of keratinizing tumors. Arch Dermatol 2012; 148:976.
- Rosendahl C, Cameron A, Argenziano G, et al. Dermoscopy of squamous cell carcinoma and keratoacanthoma. Arch Dermatol 2012; 148:1386.
- Braun RP, Rabinovitz HS, Krischer J, et al. Dermoscopy of pigmented seborrheic keratosis: a morphological study. Arch Dermatol 2002; 138:1556.
- Braun RP, Krischer J, Saurat JH. The "wobble sign" in epiluminescence microscopy as a novel clue to the differential diagnosis of pigmented skin lesions. Arch Dermatol 2000; 136:940.
- Johr RH. Pink lesions. Clin Dermatol 2002; 20:289.
- Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors. J Am Acad Dermatol 2010; 63:377.
- Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part I. Melanocytic skin tumors. J Am Acad Dermatol 2010; 63:361.
- Jaimes N, Braun RP, Thomas L, Marghoob AA. Clinical and dermoscopic characteristics of amelanotic melanomas that are not of the nodular subtype. J Eur Acad Dermatol Venereol 2012; 26:591.
- Carrera C, Marchetti MA, Dusza SW, et al. Validity and Reliability of Dermoscopic Criteria Used to Differentiate Nevi From Melanoma: A Web-Based International Dermoscopy Society Study. JAMA Dermatol 2016; 152:798.
- Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002; 3:159.
- Zalaudek I, Argenziano G, Soyer HP, et al. Three-point checklist of dermoscopy: an open internet study. Br J Dermatol 2006; 154:431.
- Dolianitis C, Kelly J, Wolfe R, Simpson P. Comparative performance of 4 dermoscopic algorithms by nonexperts for the diagnosis of melanocytic lesions. Arch Dermatol 2005; 141:1008.
- Annessi G, Bono R, Sampogna F, et al. Sensitivity, specificity, and diagnostic accuracy of three dermoscopic algorithmic methods in the diagnosis of doubtful melanocytic lesions: the importance of light brown structureless areas in differentiating atypical melanocytic nevi from thin melanomas. J Am Acad Dermatol 2007; 56:759.
- Carli P, Quercioli E, Sestini S, et al. Pattern analysis, not simplified algorithms, is the most reliable method for teaching dermoscopy for melanoma diagnosis to residents in dermatology. Br J Dermatol 2003; 148:981.
- Pagnanelli G, Soyer HP, Argenziano G, et al. Diagnosis of pigmented skin lesions by dermoscopy: web-based training improves diagnostic performance of non-experts. Br J Dermatol 2003; 148:698.
- Haenssle HA, Korpas B, Hansen-Hagge C, et al. Seven-point checklist for dermatoscopy: performance during 10 years of prospective surveillance of patients at increased melanoma risk. J Am Acad Dermatol 2010; 62:785.
- Menzies SW, Ingvar C, Crotty KA, McCarthy WH. Frequency and morphologic characteristics of invasive melanomas lacking specific surface microscopic features. Arch Dermatol 1996; 132:1178.
- Menzies SW, Kreusch J, Byth K, et al. Dermoscopic evaluation of amelanotic and hypomelanotic melanoma. Arch Dermatol 2008; 144:1120.
- Argenziano G, Catricalà C, Ardigo M, et al. Seven-point checklist of dermoscopy revisited. Br J Dermatol 2011; 164:785.
- Argenziano G, Kittler H, Ferrara G, et al. Slow-growing melanoma: a dermoscopy follow-up study. Br J Dermatol 2010; 162:267.
- Henning JS, Stein JA, Yeung J, et al. CASH algorithm for dermoscopy revisited. Arch Dermatol 2008; 144:554.
- Rosendahl C, Cameron A, McColl I, Wilkinson D. Dermatoscopy in routine practice - 'chaos and clues'. Aust Fam Physician 2012; 41:482.
- Gachon J, Beaulieu P, Sei JF, et al. First prospective study of the recognition process of melanoma in dermatological practice. Arch Dermatol 2005; 141:434.
- Buhmann JM, Malik J, Perona P. Image recognition: visual grouping, recognition, and learning. Proc Natl Acad Sci U S A 1999; 96:14203.
- Marghoob AA, Korzenko AJ, Changchien L, et al. The beauty and the beast sign in dermoscopy. Dermatol Surg 2007; 33:1388.
- Hofmann-Wellenhof R, Blum A, Wolf IH, et al. Dermoscopic classification of atypical melanocytic nevi (Clark nevi). Arch Dermatol 2001; 137:1575.
- Binder M, Schwarz M, Winkler A, et al. Epiluminescence microscopy. A useful tool for the diagnosis of pigmented skin lesions for formally trained dermatologists. Arch Dermatol 1995; 131:286.
- Bystryn JC. Epiluminescence microscopy: a reevaluation of its purpose. Arch Dermatol 2001; 137:377.
- Suh KY, Bolognia JL. Signature nevi. J Am Acad Dermatol 2009; 60:508.
- Grob JJ, Bonerandi JJ. The 'ugly duckling' sign: identification of the common characteristics of nevi in an individual as a basis for melanoma screening. Arch Dermatol 1998; 134:103.
- Argenziano G, Catricalà C, Ardigo M, et al. Dermoscopy of patients with multiple nevi: Improved management recommendations using a comparative diagnostic approach. Arch Dermatol 2011; 147:46.
- Altamura D, Avramidis M, Menzies SW. Assessment of the optimal interval for and sensitivity of short-term sequential digital dermoscopy monitoring for the diagnosis of melanoma. Arch Dermatol 2008; 144:502.
- Liu W, Hill D, Gibbs AF, et al. What features do patients notice that help to distinguish between benign pigmented lesions and melanomas?: the ABCD(E) rule versus the seven-point checklist. Melanoma Res 2005; 15:549.
- Ng PC, Barzilai DA, Ismail SA, et al. Evaluating invasive cutaneous melanoma: is the initial biopsy representative of the final depth? J Am Acad Dermatol 2003; 48:420.
- Marsden JR, Newton-Bishop JA, Burrows L, et al. Revised UK guidelines for the management of cutaneous melanoma 2010. J Plast Reconstr Aesthet Surg 2010; 63:1401.
- Coit DG, Andtbacka R, Bichakjian CK, et al. Melanoma. J Natl Compr Canc Netw 2009; 7:250.
- Menzies SW, Gutenev A, Avramidis M, et al. Short-term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001; 137:1583.
- Argenziano G, Mordente I, Ferrara G, et al. Dermoscopic monitoring of melanocytic skin lesions: clinical outcome and patient compliance vary according to follow-up protocols. Br J Dermatol 2008; 159:331.
- Fuller SR, Bowen GM, Tanner B, et al. Digital dermoscopic monitoring of atypical nevi in patients at risk for melanoma. Dermatol Surg 2007; 33:1198.
- THE TWO-STEP ALGORITHM FOR SKIN LESION EVALUATION
- FIRST STEP: MELANOCYTIC VERSUS NONMELANOCYTIC
- Criteria for melanocytic lesions
- - Dermatofibroma
- Criteria for basal cell carcinoma
- Criteria for squamous cell carcinoma
- Criteria for seborrheic keratoses
- Criteria for hemangioma/angioma and angiokeratoma
- Vascular structures in skin lesions
- Featureless lesions (feature poor, nonspecific, nonclassifiable, or structureless)
- SECOND STEP: NEVUS VERSUS SUSPICIOUS LESION OR MELANOMA
- ABCD rule of dermoscopy
- Menzies method
- The seven-point check list
- CASH algorithm
- Pattern analysis
- - Nevi: Global and local features
- - Melanoma: Global and local features
- DERMOSCOPY FROM A MANAGEMENT PERSPECTIVE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS