Search

OBJECTIVES To characterize dermoscopic criteria of squamous cell carcinoma (SCC) and keratoacanthoma and to compare them with other lesions. DESIGN Observer-masked study of consecutive lesions performed from March 1 through December 31, 2011. SETTING Primary care skin cancer practice in Brisbane, Australia. PARTICIPANTS A total of 186 patients with 206 lesions. MAIN OUTCOME MEASURES Sensitivity, specificity, predictive values, and odds ratios. RESULTS In a retrospective analysis of 60 invasive SCC and 43 keratoacanthoma cases, keratin, surface scale, blood spots, white structureless zones, white circles, and coiled vessels were commonly found in both types of lesions. We reevaluated the significance of these criteria in 206 raised, nonpigmented lesions (32 SCCs, 29 keratoacanthomas, and 145 other lesions). Central keratin was more common in keratoacanthoma than in SCC (51.2% vs 30.0%, P = .03). Keratin had the highest sensitivity for keratoacanthoma and SCC (79%), and white circles had the highest specificity (87%). When keratoacanthoma and SCC were contrasted with basal cell carcinoma, the positive predictive values of keratin and white circles were 92% and 89%, respectively. When SCC and keratoacanthoma were contrasted with actinic keratosis and Bowen disease, the positive predictive value of keratin was 50% and that of white circles was 92%. In a multivariate model, white circles, keratin, and blood spots were independent predictors of SCC and keratoacanthoma. White circles had the highest odds ratio in favor of SCC and keratoacanthoma. The interobserver agreement for white circles was good (0.55; 95% CI, 0.44-0.65). CONCLUSIONS White circles, keratin, and blood spots are useful clues to differentiate SCC and keratoacanthoma from other raised nonpigmented skin lesions by dermoscopy. The significance of these criteria depends on the clinical context.

Objective: To better characterize the dermoscopic patterns of mucosal lesions in relation to the histopathologic characteristics., Design: Retrospective and observational study., Setting: Fourteen referral pigmented lesion clinics in 10 countries., Patients: A total of 140 pigmented mucosal lesions (126 benign lesions, 11 melanomas, 2 Bowen disease lesions, and 1 metastasis) from 92 females (66%) and 48 males (34%) were collected from October 2007 through November 2008., Main Outcome Measures: Scoring the dermoscopic patterns (dots, globules, or clods, circles, lines, or structureless) and colors (brown, black, blue, gray, red, purple, and white) and correlation with the histopathologic characteristics., Results: Based on univariate analysis and 2 diagnostic models, the presence of structureless zones inside the lesions with blue, gray, or white color (the first model) had a 100% sensitivity for melanoma and 92.9% sensitivity for any malignant lesion, and 82.2% and 83.3% specificity for benign lesions in the group with melanoma lesions and the group with malignant lesions, respectively. Based on the colors (blue, gray, or white) only (the second model), the sensitivity for the group with melanoma was 100% and for the group with any malignant lesion was 92.9%, and the specificity was 64.3% and 65.1%, respectively. Patients with malignant lesions were significantly older than patients with benign lesions (mean [SD] ages, 60.1 [22.8] years vs 43.2 [17.3] years, respectively)., Conclusion: The combination of blue, gray, or white color with structureless zones are the strongest indicators when differentiating between benign and malignant mucosal lesions in dermoscopy.

Objective: To subclassify acquired nevi by dermoscopic pattern., Design: Cross-sectional study with consecutive enrollment., Setting: Pigmented lesion clinics in referral academic medical centers., Participants: Individuals older than 2 years undergoing total skin examination were consecutively recruited between October 1, 2008, and May 31, 2009, and, based on their age, assigned to 1 of 8 groups. For each patient, the location and dermoscopic pattern of all nevi on the torso were recorded. Nevi were dermoscopically subclassified as globular, reticular, mixed (reticular-globular) pattern with peripheral or central globules, or unspecified pattern., Main Outcome Measure: Frequency of dermoscopic nevus subtypes stratified by patient age and location of the nevi., Results: A total of 5481 nevi in 480 individuals were evaluated. The number of all nevus subgroups, except for unspecified pattern nevi, significantly increased before and decreased after the fourth decade of life. Globular nevi were most prevalent on the upper trunk in children and adolescents; the number decreased consistently after the second decade of life. The reticular pattern was the most common nevus pattern after the second decade of life and the most common nevus subgroup on the upper and middle back. Although uncommon, central globular nevi also showed an age-dependent trend, similar to that of reticular nevi. Nevi with the peripheral globular pattern declined rapidly after the third decade of life and were no longer observed after the sixth decade. The number of unspecified pattern nevi was stable across all age groups., Conclusion: Age, dermoscopic pattern, and location of nevi should be jointly considered when evaluating melanocytic lesions.

Objective: To assess the outcome on management recommendations of a comparative approach vs a morphologic approach in evaluating dermoscopic images of lesions from a series of patients with multiple nevi., Design: In a 2-step study, 6 experienced dermoscopists were asked to provide management recommendations (excision or follow-up) for a series of lesions from patients with multiple nevi based on dermoscopic images of the lesions. In the first step, participating dermoscopists evaluated individual images of lesions based only on morphologic structure (morphologic approach). In the second step, the same lesions were grouped by patient, allowing the participants to evaluate the lesions in the context of other nevi from the same patient (comparative approach)., Setting: Academic referral center., Patients: Seventeen patients with 190 lesions (184 monitored nevi, 4 excised nevi, and 2 excised melanomas)., Main Outcome Measure: Using pooled data from each step, excision recommendation rates for the comparative approach and the morphologic approach were calculated., Results: Using the morphologic approach, 55.1% of overall recommendations favored excision; using the comparative approach, the rate decreased to 14.1%. The 2 melanomas included in the study were correctly judged to merit excision by all participants in step 1 and in step 2. Conclusion Among patients with multiple nevi, evaluation of equivocal lesions in the context of a patient's other nevi results in a lower rate of excision recommendations compared with evaluation of individual lesions based on morphologic structure alone.

Background: Nodular melanoma (NM), representing 15% to 30% of all melanomas, constitutes nearly half of all melanomas thicker than 2 mm. Nodular melanoma frequently lacks clinical features seen in other melanoma subtypes and has a faster growth rate. We reviewed a series of cases of NM that was less than 1.3 mm thick to identify historical, clinical, and dermoscopic factors that may facilitate earlier diagnosis of NM, with the hope of reducing its associated morbidity and mortality., Observations: The thin NM lesions we analyzed had a rather subtle clinical appearance, often lacking the ABCD (asymmetry, border irregularity, color variegation, and diameter greater than 6 mm) criteria. On dermoscopy, most lesions had a homogeneous disorganized asymmetric pattern or a featureless pattern with atypical vessels. Although many dermoscopic features seen in other melanoma subtypes were frequently absent, some features such as a blue-white veil, structureless areas, and atypical vascular structures were often identified., Conclusions: The often unremarkable clinical presentation of NM necessitates physicians and patients to be wary of new or changing lesions. Dermoscopy may help increase suspicion in early NM because dermoscopic features are typically more suggestive of malignancy than clinical ones. We hope that secondary prevention efforts combined with prompt dermatologic consultations will allow for the timely diagnosis and management of NM.

Objective: To review recent dermoscopy studies that provide new insights into the evolution of nevi and their patterns of pigmentation as they contribute to the diagnosis of nevi and the management of pigmented melanocytic nevi., Data Sources: Data for this article were identified by searching the English and German literature by Medline and Journals@Ovid search for the period 1950 to January 2009., Study Selection: The following relevant terms were used: dermoscopy, dermatoscopy, epiluminescence microscopy (ELM), surface microscopy, digital dermoscopy, digital dermatoscopy, digital epiluminescence microscopy, digital surface microscopy, melanocytic skin lesion, nevi, and pigmented skin lesions. There were no exclusion criteria., Data Synthesis: The dermoscopic diagnosis of nevi relies on the following 4 criteria (each of which is characterized by 4 variables): (1) color (black, brown, gray, and blue); (2) pattern (globular, reticular, starburst, and homogeneous blue pattern); (3) pigment distribution (multifocal, central, eccentric, and uniform); and (4) special sites (face, acral areas, nail, and mucosa). In addition, the following 6 factors related to the patient might influence the pattern of pigmentation of the individual nevi: age, skin type, history of melanoma, UV exposure, pregnancy, and growth dynamics., Conclusions: The 4 x 4 x 6 "rule" may help clinicians remember the basic dermoscopic criteria of nevi and the patient-related factors influencing their patterns. Dermoscopy is a useful technique for diagnosing melanocytic nevi, but the clinician should take additional factors into consideration to optimize the management of cases of pigmented lesions.

Objective: To determine the predictive dermoscopic features of amelanotic and hypomelanotic melanoma., Design: A total of 105 melanomas (median Breslow thickness, 0.76 mm), 170 benign melanocytic lesions, and 222 nonmelanocytic lesions lacking significant pigment (amelanotic, partially pigmented, and light colored) were imaged using glass-plate dermoscopy devices and scored for 99 dermoscopic features. Diagnostic models were derived from and tested on independent randomly selected lesions., Setting: Predominantly hospital-based clinics from 5 continents., Main Outcome Measures: Sensitivity, specificity, and odds ratios for individual features and models for the diagnosis of melanoma and malignancy., Results: The most significant negative predictors of melanoma were having multiple (>3) milialike cysts (odds ratio, 0.09; 95% confidence interval, 0.01-0.64), comma vessels with a regular distribution (0.10; 0.01-0.70), comma vessels as the predominant vessel type (0.16; 0.05-0.52), symmetrical pigmentation pattern (0.18; 0.09-0.39), irregular blue-gray globules (0.20; 0.05-0.87), and multiple blue-gray globules (0.28; 0.10-0.81). The most significant positive predictors were having a blue-white veil (odds ratio,13; 95% confidence interval, 3.9-40.0), scarlike depigmentation (4.4; 2.4-8.0), multiple blue-gray dots (3.5; 1.9-6.4), irregularly shaped depigmentation (3.3; 2.0-5.3), irregular brown dots/globules (3.2; 1.8-5.6), 5 to 6 colors (3.2; 1.6-6.3), and predominant central vessels (3.1; 1.6-6.0). A simple model distinguishing melanomas from all nonmelanomas had a sensitivity of 70% and a specificity of 56% in the test set. A model distinguishing all malignant lesions from benign lesions had a sensitivity of 96% and a specificity of 37%. Conclusion Although the diagnostic accuracy of dermoscopy for melanoma lacking significant pigment is inferior to that of more pigmented lesions, features distinguishing the former from benign lesions can be visualized on dermoscopic evaluation.

Objective: To determine the time required to perform a complete skin examination (CSE) as a means of opportunistic screening for skin cancer both without and with dermoscopy., Design: Randomized, prospective multicenter study., Setting: Eight referral pigmented lesion clinics. Patients From June 2006 to January 2007, 1359 patients with at least 1 melanocytic or nonmelanocytic skin lesion were randomly selected to receive a CSE without dermoscopy or CSE with dermoscopy. For each patient, the total number of lesions and the duration of the CSE were recorded. A total of 1328 patients were eligible for analysis (31 were excluded because of missing data)., Main Outcome Measures: The median time (measured in seconds) needed for CSE with and without dermoscopy and according to total cutaneous lesion count., Results: The median time needed for CSE without dermoscopy was 70 seconds and with dermoscopy was 142 seconds, a significant difference of 72 seconds (P < .001). The use of dermoscopy increased the duration of CSE, and this increase was in direct proportion to the patient's total lesion count. In contrast, the time required to perform a CSE without dermoscopy remained the same irrespective of whether the patients had few or many lesions., Conclusions: A CSE aided by dermoscopy takes significantly longer than a CSE without dermoscopy. However, a thorough CSE, with or without dermoscopy, requires less than 3 minutes, which is a reasonable amount of added time to potentially prevent the morbidity and mortality associated with skin cancer.

Objectives: To assess whether multiple observers can identify the same pigmented lesion(s) as being different from a patient's other moles ("ugly duckling" [UD] sign) and to explore whether the UD sign is sensitive for melanoma detection., Design: Baseline back images of 12 patients were obtained from a database of standardized patient images. All patients had at least 8 atypical moles on the back, and in 5 patients, one of the lesions was a histologically confirmed melanoma. The overview back images were supplemented with close-up clinical images of lesions. Participants were asked to evaluate whether the images showed any lesions on the back that differed from other nevi., Setting: Dermatology clinic specializing in pigmented lesions., Participants: Images were evaluated by 34 participants, including 8 pigmented lesion experts, 13 general dermatologists, 5 dermatology nurses, and 8 nonclinical medical staff., Main Outcome Measures: A lesion was considered a generally apparent UD if it was perceived as different by at least two-thirds of the participants. Sensitivity was defined as the fraction of melanomas identified as different., Results: All 5 melanomas (100%) and only 3 of 140 benign lesions (2.1%) were generally apparent as different. The sensitivity of the UD sign for melanoma detection was 0.9 for the whole group, 1.0 for experts, 0.89 for general dermatologists, 0.88 for nurses, and 0.85 for nonclinicians. A limitation of the study is that assessment was done in virtual settings., Conclusions: In the present study, melanomas were generally apparent as UDs. The potential of the UD sign for melanoma screening should be further assessed.

Objective: To investigate changes in dermoscopic patterns of acquired acral melanocytic nevi (AAMN) over time., Design: Retrospective analysis of digital dermoscopic follow-up of 230 AAMN located on acral volar skin., Setting: Outpatient clinics at university dermatology departments. Patients A total of 230 AAMN located on the soles (n = 149), fingers (n = 62), and palms (n = 19), of 230 white subjects 14 years or younger (n = 81), 15 to 30 years (n = 72), and older than 30 years (n = 77)., Main Outcome Measure: Comparison of baseline and follow-up dermoscopic patterns., Results: Individual AAMN had a digital follow-up of 6 months (n = 59), 12 months (n = 74), 18 months (n = 44), and 24 months (n = 53). Baseline dermoscopic images showed the following patterns: parallel furrow (48.8%), latticelike (16.1%), fibrillar (10.9%), nontypical (10.9%), homogeneous (4.8%), globular (3.5%), transition (3.5%), and reticular (2.6%). Dermoscopic changes over time were observed in 42 of the 230 AAMN (18.3%), with the greatest frequency of changes occurring in patients 14 years or younger (23 of 81 lesions; 28.4%) (P = .005). The parallel furrow pattern (25.9%) showed more variations over time than other dermoscopic patterns (11.0%) (P = .004). The frequency of change increased linearly over time (P = .001). Four of 7 clinically regressing nevi showed a homogeneous pattern at the last examination., Conclusions: Dermoscopic changes of AAMN are most common in subjects younger than 14 years. The parallel furrow pattern appears to be the dermoscopic pattern most subject to change, while the homogeneous pattern may be seen also in AAMN showing clinical and dermoscopic involution.

Background: Dermoscopic classification of acquired melanocytic nevi (AMN) is based on the evaluation of 3 main criteria-global pattern, pigment distribution, and color., Objective: To determine whether these features are different in AMN in white people with different skin types (STs) according to the Fitzpatrick classification., Design: Digital dermoscopic images of AMN were evaluated, and the correlation of the 3 main dermoscopic criteria with patient ST was analyzed., Setting: Consecutive patients were recruited from 7 pigmented lesion clinics between June 1, 2004, and June 30, 2005. Patients For each patient, the ST (I [always burns, never tans] to IV [rarely burns, tans with ease]) was scored, and 1 representative AMN (defined as the AMN showing a dermoscopic typology that is repeatedly seen in the same patient) was selected and photographed., Main Outcome Measures: The distribution of the dermoscopic criteria of AMN in patients with different STs was calculated by univariate analysis. Differences in prevalence were tested using the chi(2) test. The correlation between dermoscopic criteria and ST, adjusted for age, sex, and enrolling center, was evaluated by calculating odds ratios and 95% confidence intervals by logistic regression analysis., Results: Of 680 included patients, dermoscopic analysis revealed significant differences in the prevalent nevus pattern in the 4 ST groups. Light brown AMN with central hypopigmentation were associated with ST I, and ST IV was associated with the so-called black nevus (P<.001), typified by reticular pattern, central hyperpigmentation, and dark brown coloration. A significant association was also found between multifocal pattern and ST II and ST III., Conclusions: The dermoscopic nevus type varies according to different ST in white people. This knowledge may have an effect on obtaining for biopsy lesions that exhibit unusual dermoscopic patterns when patient ST is considered.

Objectives: To describe the dermoscopic structures and patterns associated with solitary angiokeratomas and to determine the sensitivity, specificity, positive predictive value, negative predictive value, and reproducibility of these dermoscopic features., Design: Multicenter retrospective study., Setting: University hospitals in Spain, Italy, Argentina, New York City, and Austria., Patients: There were 256 patients total, and 32 specimens each of solitary angiokeratomas, melanocytic nevi, Spitz-Reed nevi, malignant melanomas, pigmented basal cell carcinomas, dermatofibromas, seborrheic keratoses, and other vascular lesions (19 angiomas, 7 pyogenic granulomas, 3 spider nevi, 2 lymphangiomas, and 1 venous lake) were consecutively collected from the laboratories of 8 hospitals. Diagnoses of all patients' lesions were confirmed histopathologically., Intervention: Dermoscopic examination., Main Outcome Measures: The frequency, sensitivity, specificity, positive predictive value, negative predictive value, intraobserver agreement, and interobserver agreement of the different dermoscopic features associated with solitary angiokeratomas were calculated, and the differences were evaluated using the chi(2) or Fisher exact test., Results: Six dermoscopic structures were evident in at least 50% of the solitary angiokeratomas: dark lacunae (94%), whitish veil (91%), erythema (69%), peripheral erythema (53%), red lacunae (53%), and hemorrhagic crusts (53%). Dark lacunae exhibited a sensitivity of 93.8% and a specificity of 99.1% (P<.001 for both), not being found in malignant melanomas or pigmented basal cell carcinomas. The positive predictive value was 93.8%, and the negative predictive value was 99.1%. The intraobserver agreement was perfect (kappa, 1.00), and the interobserver agreement was excellent (kappa range, 0.83-1.00) (P<.001 for both). Pattern 1, consisting of dark lacunae and whitish veil, exhibited a sensitivity of 84.4% and a specificity of 99.1% and was not found in malignant melanomas or pigmented basal cell carcinomas. The positive predictive value was 93.1%, the negative predictive value was 97.8%, the intraobserver agreement was perfect (kappa, 1.00), and the interobserver agreement was excellent (kappa range, 0.83-1.00) (P<.001 for all). Conclusion Dermoscopy is helpful in improving the diagnostic accuracy of solitary angiokeratomas and allows the observer to differentiate them from other cutaneous tumors such as malignant melanomas and pigmented basal cell carcinomas.

Background: Halo nevi (HN) are benign melanocytic nevi surrounded by a depigmented area (halo). This study aims to evaluate the dermoscopic features of HN and their changes during digital dermoscopic follow-up and to investigate the frequency of the halo phenomenon in a series of melanomas., Observations: In a retrospective study, digital dermoscopic images of HN from patients who attended the Pigmented Skin Lesions Clinic of the Department of Dermatology, Medical University of Graz, between October 1, 1997, and March 31, 2004, were reviewed and classified by dermoscopic morphologic criteria. For HN that were followed up with digital dermoscopy, the percentages of changes in the size of the nevus and halo components were calculated. In addition, digital dermoscopic images of histopathologically confirmed melanomas obtained from the same database were reviewed for the presence of an encircling halolike depigmentation. We classified 138 HN in 87 patients (mean age, 22.4 years). The most common dermoscopic structures were the globular and/or homogeneous patterns in more than 80% of HN. Follow-up of 33 HN revealed considerable size reduction of the nevus component, but this was not associated with significant structural changes. Of a total of 475 melanomas, only 2 revealed an encircling halo, but both displayed clear-cut melanoma-specific patterns according to dermoscopy., Conclusions: Halo nevi exhibit the characteristic dermoscopic features of benign melanocytic nevi, represented by globular and/or homogeneous patterns that are typically observed in children and young adults. Halo nevi reveal considerable changes of area over time during digital dermoscopic follow-up, albeit their structural patterns remain unchanged. For this reason and because melanoma with halolike depigmentation, despite being rare, additionally exhibits melanoma-specific dermoscopic criteria, the role of digital dermoscopic follow-up in the diagnosis of HN is insignificant.

Background: Fibroepithelioma of Pinkus (FeP) is a rare variant of basal cell carcinoma that may clinically mimic a number of benign skin tumors. While the dermoscopic features of basal cell carcinoma have been studied extensively, little is known about the dermoscopic features of FeP., Observations: Retrospective evaluation of clinical records and digital clinical dermoscopic images of 10 histopathologically proved FePs (6 nonpigmented and 4 pigmented) was performed. Clinically, no FeP was correctly identified and, in half of all patients, a clinical differential diagnosis of purely benign skin lesions was made. Dermoscopy enabled the correct diagnosis in 9 of 10 FePs, based on the presence of fine arborizing vessels, either alone or associated with dotted vessels, and white streaks (in 100%, 70%, and 90% of lesions, respectively). In the 4 pigmented FePs, a structureless gray-brown area of pigmentation and variable numbers of gray-blue dots were observed, in addition., Conclusions: Dermoscopy is helpful in diagnosing FeP and in differentiating this variant of basal cell carcinoma from other benign skin tumors commonly included in the clinical differential diagnosis. This presumes, however, that dermoscopy is used as a first-line examination for all skin lesions, not only for those that are clinically suspect.

Objective: To achieve a clinicopathologic classification of Spitz nevi by comparing their clinical, dermoscopic, and histopathologic features., Design: Eighty-three cases were independently reviewed by 3 histopathologists and preliminarily classified into classic or desmoplastic Spitz nevus (CDSN, n = 11), pigmented Spitz nevus (PSN, n = 14), Reed nevus (RN, n = 16), or atypical Spitz nevus (ASN, n = 14); the remaining 28 cases were then placed into an intermediate category (pigmented Spitz-Reed nevus, PSRN) because a unanimous diagnosis of either PSN or RN was not reached., Setting: University dermatology and pathology departments and general hospital pathology departments., Patients: A sample of subjects with excised melanocytic lesions., Main Outcome Measure: Frequency of dermoscopic patterns within the different histopathologic subtypes of Spitz nevi., Results: Overlapping clinical, dermoscopic, and histopathologic findings were observed among PSN, RN, and PSRN, thereby justifying their inclusion into the single PSRN diagnostic category. Asymmetry was the most frequent indicator of histopathologic ASN (79%; n = 11); in only 4 cases did dermoscopic asymmetry show no histopathologic counterpart, and in those cases the discrepancy was probably the result of an artifact of the gross sampling technique carried out with no attention to the dermoscopic features., Conclusions: Among Spitz nevi, histopathologic distinction between PSN and RN is difficult, not reproducible, and may be clinically useless. A simple clinicopathologic classification of these neoplasms might therefore be structured as CDSN, PSRN, and ASN. Asymmetry should be assessed using both dermoscopic and histopathologic analysis, and reliability in histopathologic diagnosis may be enhanced by the simultaneous evaluation of the corresponding dermoscopic images.

Objectives: To describe the different vascular structures seen by dermoscopy and to evaluate their association with various melanocytic and nonmelanocytic skin tumors in a large series of cases., Design: Digital dermoscopic images of the lesions were evaluated for the presence of various morphologic types of vessels., Setting: Specialized university clinic., Patients: From a larger database, 531 excised lesions (from 517 patients) dermoscopically showing any type of vascular structures were included., Main Outcome Measures: The frequency and positive predictive value of the different vascular structures seen in various tumors were calculated, and the differences were evaluated by the chi2 or Fisher exact test., Results: Arborizing vessels were seen in 82.1% of basal cell carcinomas, with a 94.1% positive predictive value (P<.001). Dotted vessels were generally predictive for a melanocytic lesion (90.0%, P<.001), and were especially seen in Spitz nevi (77.8% of lesions). In melanoma, linear-irregular, dotted, and polymorphous/atypical vessels were the most frequent vascular structures, whereas milky-red globules/areas were the most predictive ones (77.8%, P = .003). The presence of erythema was most predictive for Clark nevus, whereas comma, glomerular, crown, and hairpin vessels were significantly associated with dermal/congenital nevi, Bowen disease, sebaceous hyperplasia, and seborrheic keratosis, respectively (P<.001 for all)., Conclusions: Different morphologic types of vessels are associated with different melanocytic or nonmelanocytic skin tumors. Therefore, the recognition of distinctive vascular structures may be helpful for diagnostic purposes, especially when the classic pigmented dermoscopic structures are lacking.