CLINICAL REVIEW
Dermoscopy of pigmented skin lesions
Ralph Peter Braun, MD,a
Harold S. Rabinovitz, MD,b
Margaret Oliviero,...
PHYSICAL ASPECTS
Light is either reflected, dispersed, or absorbed by
the stratum corneum because of its refraction index
a...
pigment network is either melanin pigment in
keratinocytes, or in melanocytes along the dermoe-
pidermal junction.40
The r...
Fig 3. A, Macroscopic picture of a superficial spreading malignant melanoma (Breslow
thickness 0.52 mm; Clark level II). B...
pseudopods. This is because both these structures
have the same histopathological correlation.11,37,42,46
Streaks can be i...
Histopathologically this corresponds to an aggrega-
tion of heavily pigmented cells or melanin in the
dermis (blue color) ...
Large blue-gray ovoid nests. Ovoid nests are
large, well-circumscribed, confluent or near-con-
fluent, pigmented ovoid areas...
DIFFERENTIAL DIAGNOSIS OF
PIGMENTED LESIONS OF THE SKIN
There are many publications on the subject of the
differential dia...
considered ‘‘suspicious’’ and should therefore be
monitored closely or removed.11,70
7-point checklist
In 1998 Argenziano ...
of a melanocytic nevus (Clark nevus, dysplastic
nevus).32,36,71
Another pattern is the so-called globular pattern.
It is c...
14. Binder M, Schwarz M, Winkler A, Steiner A, Kaider A, Wolff K,
et al. Epiluminescence microscopy. A useful tool for the...
morphological features to identify malignant melanoma.
Pigment Cell Res 1992:295-8.
57. Kreusch J, Koch F. Auflichtmikrosk...
95. Braun RP, Meier M, Pelloni F, Ramelet AA, Schilling M,
Tapernoux B, et al. Teledermatoscopy in Switzerland: a pre-
lim...
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Dermoscopy of pigmented skin lesions

  1. 1. 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, MDa 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.) In 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 review of 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 MacKie30 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 Hamburg31 and the Consensus Netmeeting on Dermoscopy, which was held in 2001 in Rome32 (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 Genevaa ; Skin and Cancer Associates, Plantation, Fla, and Department of Dermatology, University of Miami School of Medicineb ; 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 ª 2005 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2001.11.001 109
  2. 2. PHYSICAL ASPECTS Light is either reflected, 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 magnification 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 Pra¨zisionsoptik]; 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 identification 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 revisions32 : 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 Koch57 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, Bowen’s 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
  3. 3. 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 stratum corneum and 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 expression of an altered pigmented network in which 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 fingerlike 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 al49 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 classification 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
  4. 4. 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
  5. 5. 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 (Reed’s 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 fibrosis, loss of pig- mentation, epidermalthinning,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, confluent 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
  6. 6. 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-filled 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-filled 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 flat sebor- rheic keratoses (also known as solar lentigines) can show tiny ridges running parallel and producing a pattern that resembles fingerprints.11,32,65,66 Moth-eaten border. Some flat 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 finger 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 al39 (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 JANUARY 2005 114 Braun et al
  7. 7. Large blue-gray ovoid nests. Ovoid nests are large, well-circumscribed, confluent or near-con- fluent, 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. Cont’d 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 J AM ACAD DERMATOL VOLUME 52, NUMBER 1 Braun et al 115
  8. 8. 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 analysis8,39,62 ; the ABCD rule of dermo- scopy11,45,70 ; the 7-point checklist32,36,44 ; the Menzies method13,32,49 ; and the revised pattern analysis.71 The Board of the Consensus Netmeeting agreed on a two-step procedure for the classification of pigmented lesions of the skin (Fig 1). A similar approach has been proposed by other authors in the past. The first 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 identified 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 al44 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 al13,49 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 JANUARY 2005 116 Braun et al
  9. 9. 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 method13,32,49 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
  10. 10. 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 field is teledermoscopy. At the beginning of the digital dermoscopic era, tele- dermoscopy was used between experts to exchange difficult 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 World57,69 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. REFERENCES 1. Rigel DS, Friedman RJ, Kopf AW. The incidence of malignant melanoma in the United States: Issues as we approach the 21st century. J Am Acad Dermatol 1996;34:839-47. 2. Rigel DS, Friedman RJ, Kopf AW. Lifetime risk for development of skin cancer in the U.S. population: current estimate is now 1 in 5. J Am Acad Dermatol 1996;35:1012-3. 3. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA Cancer J Clin 1999;49:8-31. 4. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998. CA Cancer J Clin 1998;48:6-29. 5. Rigel DS, Carucci JA. Malignant melanoma: prevention, early detection, and treatment in the 21st century. CA Cancer J Clin 2000;50:215-36. 6. Burton RC. Malignant melanoma in the year 2000. CA Cancer J Clin 2000;50:209-13. 7. Rigel DS. Malignant melanoma: perspectives on incidence and its effects on awareness, diagnosis, and treatment. CA Cancer J Clin 1996;46:195-8. 8. Pehamberger H, Binder M, Steiner A, Wolff K. In vivo epiluminescence microscopy: improvement of early diagnosis of melanoma. J Invest Dermatol 1993;100:356S-62S. 9. Soyer HP, Argenziano G, Chimenti S, Ruocco V. Dermoscopy of pigmented skin lesions. Eur J Dermatol 2001;11:270-6. 10. Soyer HP, Argenziano G, Talamini R, Chimenti S. Is dermoscopy useful for the diagnosis of melanoma? Arch Dermatol 2001;137:1361-3. 11. Stolz W, Braun-Falco O, Bilek P, Landthaler M, Burgdorf WHC, Cognetta AB. Color alas of drmatoscopy. 2nd ed. Berlin: Blackwell Wissenschafts-Verlag; 2002. 12. Mayer J. Systematic review of the diagnostic accuracy of dermatoscopy in detecting malignant melanoma. Med J Aust 1997;167:206-10. 13. Menzies SW, Crotty KA, Ingvar C, McCarthy WH. An atlas of surface microscopy of pigmented skin lesions. Sydney: McGraw-Hill Book Company; 2003. J AM ACAD DERMATOL JANUARY 2005 118 Braun et al
  11. 11. 14. Binder M, Schwarz M, Winkler A, Steiner A, Kaider A, Wolff K, et al. Epiluminescence microscopy. A useful tool for the di- agnosis of pigmented skin lesions for formally trained dermatologists. Arch Dermatol 1995;131:286-91. 15. Binder M, Puespoeck-Schwarz M, Steiner A, Kittler H, Muellner M, Wolff K, et al. Epiluminescence microscopy of small pigmented skin lesions: short-term formal training improves the diagnostic performance of dermatologists. J Am Acad Dermatol 1997;36:197-202. 16. Westerhoff K, McCarthy WH, Menzies SW. Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy. Br J Dermatol 2000;143: 1016-20. 17. Bafounta ML, Beauchet A, Aegerter P, Saiag P. Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the evaluation of diagnostic tests. Arch Dermatol 2001;137:1343-50. 18. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002;3:159-65. 19. Gilje O, O’Leary PA, Baldes EY. Capillary microscopic examina- tion in skin siease. Arch Dermatol 1958;68:136-45. 20. Diepgen P. Geschichte der Medizin. Berlin: De Gruyter; 1965. 21. Unna P. Die Diaskopie der Hautkrankheiten. Berl Klin Wochen 1885;42:1016-21. 22. Saphier J. Die Dermatoskopie. I. Mitteilung. Arch Dermatol Syphiol 1920;128:1-19. 23. Saphier J. Die Dermatoskopie. II. Mitteilung. Arch Dermatol Syphiol 1921;132:69-86. 24. Saphier J. Die Dermatoskopie. IV. Mitteilung. Arch Dermatol Syphiol 1921;136:149-58. 25. Saphier J. Die Dermatoskopie. III. Mitteilung. Arch Dermatol Syphiol 2002;134:314-22. 26. Goldman L. Some investigative studies of pigmented nevi with cutaneous microscopy. J Invest Dermatol 1951;16:407-26. 27. Goldman L. Clinical studies in microscopy of the skin at moderate magnification. Arch Dermatol 1957;75:345-60. 28. Goldman L. A simple portable skin microscope for surface microscopy. Arch Dermatol 1958;78:246-7. 29. Goldman L. Direct skin microscopy as an aid in the early diagnosis of precancer and cancer of the skin in the elderly. J Am Geriatr Soc 1980;28:337-40. 30. MacKie RM. An aid to the preoperative assessment of pigmented lesions of the skin. Br J Dermatol 1971;85:232-8. 31. Bahmer FA, Fritsch P, Kreusch J, Pehamberger H, Rohrer C, Schindera I, et al. Diagnostische Kriterien in der Auflichtsmik- roskopie. Konsensus-Treffen der Arbeitsgruppe Analytische Morphologie der Arbeitsgemeinschaft Dermatologische For- schung,17November1989inHamburg.Hautarzt1990;41:513-4. 32. Argenziano G, Soyer HP, Chimenti S, Talamini R, Corona R, Sera F, et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol 2003;48:679-93. 33. Anderson RR, Parrish JA. The optics of human skin. J Invest Dermatol 1981;77:13-9. 34. Braun RP, Saurat JH, Krischer J. Diagnostic pearl: unmagnified diascopy for large pigmented lesions reveals features similar to those of epiluminescence microscopy. J Am Acad Dermatol 1999;41:765-6. 35. Bahmer FA, Rohrer C. Rapid and simple macrophotography of the skin. Br J Dermatol 1986;114:135-6. 36. Argenziano G, Soyer HP, De Giorgi V, Piccolo D, Carli P, Delfino M, et al. Dermoscopy: a tutorial. 1st ed. Milano: EDRA; 2000. 37. Kenet RO, Kang S, Kenet BJ, Fitzpatrick TB, Sober AJ, Barnhill RL. Clinical diagnosis of pigmented lesions using digital epiluminescence microscopy. Grading protocol and atlas. Arch Dermatol 1993;129:157-74. 38. Reisfeld PL. Blue in the skin. J Am Acad Dermatol 2000;42: 597-605. 39. 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;17:571-83. 40. Krischer J, Skaria A, Guillod J, Lemonnier E, Salomon D, Braun R, et al. Epiluminescent light microscopy of melanocytic lesions after dermoepidermal split. Dermatology 1997; 195:108-11. 41. Massi D, De Giorgi V, Soyer HP. Histopathologic correlates of dermoscopic criteria. Dermatol Clin 2001;19:259-68. 42. Soyer HP, Kenet RO, Wolf IH, Kenet BJ, Cerroni L. Clinicopath- ological correlation of pigmented skin lesions using dermo- scopy. Eur J Dermatol 2000;10:22-8. 43. Yadav S, Vossaert KA, Kopf AW, Silverman M, Grin-Jorgensen C. Histopathologic correlates of structures seen on dermo- scopy (epiluminescence microscopy). Am J Dermatopathol 1993;15:297-305. 44. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Sammarco E, Delfino M. 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;134:1563-70. 45. Nachbar F, Stolz W, Merkle T, Cognetta AB, Vogt T, Landthaler M, et al. The ABCD rule of dermatoscopy: high prospective value in the diagnosis of doubtful melanocytic skin lesions. J Am Acad Dermatol 1994;30:551-9. 46. Soyer HP, Smolle J, Ho¨dl S, Pachernegg H, Kerl H. Surface microscopy: a new approach to the diagnosis of cutaneous pigmented tumors. Am J Dermatopathol 1989;11:1-10. 47. Guillod JF, Skaria AM, Salomon D, Saurat JH. Epiluminescence videomicroscopy: black dots and brown globules revisited by stripping the stratum corneum. J Am Acad Dermatol 1997;36:371-7. 48. Kittler H, Seltenheim M, Dawid M, Pehamberger H, Wolff K, Binder M. Frequency and characteristics of enlarging common melanocytic nevi. Arch Dermatol 2000;136:316-20. 49. Menzies SW, Ingvar C, McCarthy WH. A sensitivity and specificity analysis of the surface microscopy features of invasive melanoma. Melanoma Res 1996;6:55-62. 50. Menzies SW, Crotty KA, McCarthy WH. The morphologic criteria of the pseudopod in surface microscopy. Arch Dermatol 1995;131:436-40. 51. Argenziano G, Scalvenzi M, Staibano S, Brunetti B, Piccolo D, Delfino M, et al. Dermatoscopic pitfalls in differentiating pigmented Spitz naevi from cutaneous melanomas. Br J Dermatol 1999;141:788-93. 52. Argenziano G, Soyer HP, Ferrara G, Piccolo D, Hofmann- Wellenhof R, Peris K, et al. Superficial black network: an additional dermoscopic clue for the diagnosis of pigmented spindle and/or epithelioid cell nevus. Dermatology 2001; 203:333-5. 53. Steiner A, Pehamberger H, Binder M, Wolff K. Pigmented Spitz nevi: improvement of the diagnostic accuracy by epilumines- cence microscopy. J Am Acad Dermatol 1992;27:697-701. 54. Massi D, De Giorgi V, Carli P, Santucci M. Diagnostic significance of the blue hue in dermoscopy of melanocytic lesions: a dermoscopic-pathologic study. Am J Dermatopathol 2001;23:463-9. 55. Kreusch J, Rassner G. Auflichtmikroskopie pigmentierter Hauttumoren. Stuttgart: Thieme; 1991. 56. Kreusch J, Rassner G, Trahn C, Pietsch-Breitfeld B, Henke D, Selbmann HK. Epiluminescent microscopy: a score of J AM ACAD DERMATOL VOLUME 52, NUMBER 1 Braun et al 119
  12. 12. morphological features to identify malignant melanoma. Pigment Cell Res 1992:295-8. 57. Kreusch J, Koch F. Auflichtmikroskopische Charakterisierung von Gefassmustern in Hauttumoren. Hautarzt 1996;47:264-72. 58. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Delfino M. Epiluminescence microscopy: criteria of cutaneous melanoma progression. J Am Acad Dermatol 1997;37:68-74. 59. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Delfino M. Clinical and dermatoscopic criteria for the preoperative evaluation of cutaneous melanoma thickness. J Am Acad Dermatol 1999;40:61-8. 60. Argenyi ZB. Dermoscopy (epiluminescence microscopy) of pigmented skin lesions. Current status and evolving trends. Dermatol Clin 1997;15:79-95. 61. Carli P, De Giorgi V, Soyer HP, Stante M, Mannone F, Giannotti B. Dermatoscopy in the diagnosis of pigmented skin lesions: a new semiology for the dermatologist. J Eur Acad Dermatol Venereol 2000;14:353-69. 62. Steiner A, Pehamberger H, Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions. II. Diagnosis of small pigmented skin lesions and early detection of malignant melanoma. J Am Acad Dermatol 1987;17:584-91. 63. Braun RP, Rabinovitz H, Krischer J, Kreusch J, Oliviero M, Naldi L, et al. Dermoscopy of pigmented seborrheic keratosis. Arch Dermatol 2002;138:1556-60. 64. Provost N, Kopf AW, Rabinovitz HS, Oliviero MC, Toussaint S, Kamino HH. Globulelike dermoscopic structures in pigmented seborrheic keratosis. Arch Dermatol 1997;133:540-1. 65. Braun RP, Rabinovitz H, Oliviero M, Kopf AW, Saurat JH, Thomas L. Dermatoscopy of pigmented lesions. Ann Dermatol Venereol 2002;129:187-202. 66. Schiffner R, Schiffner-Rohe J, Vogt T, Landthaler M, Wlotzke U, Cognetta AB, et al. Improvement of early recognition of lentigo maligna using dermatoscopy. J Am Acad Dermatol 2000;42:25-32. 67. Menzies SW, Westerhoff K, Rabinovitz H, Kopf AW, McCarthy WH, Katz B. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000;136:1012-6. 68. Soyer HP, Argenziano G, Ruocco V, Chimenti S. Dermoscopy of pigmented skin lesions (Part II). Eur J Dermatol 2001;11: 483-98. 69. Wang SQ, Katz B, Rabinovitz H, Kopf AW, Oliviero M. Lessons on dermoscopy #4. Poorly defined pigmented lesion. Di- agnosis: pigmented BCC. Dermatol Surg 2000;26:605-6. 70. Stolz W, Riemann A, Cognetta AB, Pillet L, Abmayr W, Ho¨lzel D, et al. ABCD rule of Dermatoscopy: a new practical method for early recognition of malignant melanoma. Eur J Dermatol 1994;4:521-7. 71. Braun RP, Rabinovitz H, Oliviero M, Kopf AW, Saurat JH. Pattern analysis: a two step procedure for the dermoscopic diagnosis of melanoma. Clin Dermatol 2002;20:236-9. 72. Saida T, Oguchi S, Ishihara Y. In vivo observation of magnified features of pigmented lesions on volar skin using video macroscope. Usefulness of epiluminescence techniques in clinical diagnosis. Arch Dermatol 1995;131:298-304. 73. Cognetta AB Jr, Stolz W, Katz B, Tullos J, Gossain S. Dermato- scopy of lentigo maligna. Dermatol Clin 2001;19:307-18. 74. Kittler H, Seltenheim M, Pehamberger H, Wolff K, Binder M. Diagnostic informativeness of compressed digital epilumines- cence microscopy images of pigmented skin lesions com- pared with photographs. Melanoma Res 1998;8:255-60. 75. Braun RP, Lemonnier E, Guillod J, Skaria A, Salomon D, Saurat JH. Two types of pattern modification detected on the follow- up of benign melanocytic skin lesions by digitized epilumi- nescence microscopy. Melanoma Res 1998;8:431-7. 76. Kittler H, Pehamberger H, Wolff K, Binder M. Follow-up of melanocytic skin lesions with digital epiluminescence micros- copy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol 2000;43:467-76. 77. Menzies SW, Gutenev A, Avramidis M, Batrac A, McCarthy WH. Short-term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001;137:1583-9. 78. Stolz W, Schiffner R, Pillet L, Vogt T, Harms H, Schindewolf T, et al. Improvement of monitoring of melanocytic skin lesions with the use of a computerized acquisition and surveillance unit with a skin surface microscopic television camera. J Am Acad Dermatol 1996;35:202-7. 79. Binder M, Steiner A, Schwarz M, Knollmayer S, Wolff K, Pehamberger H. Application of an artificial neural network in epiluminescence microscopy pattern analysis of pigmented skin lesions: a pilot study. Br J Dermatol 1994;130:460-5. 80. Binder M, Kittler H, Seeber A, Steiner A, Pehamberger H, Wolff K. Epiluminescence microscopy-based classification of pig- mented skin lesions using computerized image analysis and an artificial neural network. Melanoma Res 1998;8:261-6. 81. Binder M, Kittler H, Dreiseitl S, Ganster H, Wolff K, Peham- berger H. Computer-aided epiluminescence microscopy of pigmented skin lesions: the value of clinical data for the classification process. Melanoma Res 2000;10:556-61. 82. Day GR, Barbour RH. Automated melanoma diagnosis: where are we at? Skin Res Technol 2000;6:1-5. 83. Debeir O, Decaestecker C, Pasteels JL, Salmon I, Kiss R, Van Ham P. Computer-assisted analysis of epiluminescence mi- croscopy images of pigmented skin lesions. Cytometry 1999;37:255-66. 84. Elbaum M, Kopf AW, Rabinovitz HS, Langley RG, Kamino H, Mihm MC Jr, et al. Automatic differentiation of melanoma from melanocytic nevi with multispectral digital dermoscopy: a feasibility study. J Am Acad Dermatol 2001;44:207-18. 85. Fleming MG, Steger C, Zhang J, Gao J, Cognetta AB, Pollak I, et al. Techniques for a structural analysis of dermatoscopic imagery. Comput Med Imaging Graph 1998;22:375-89. 86. Gutenev A, Skladnev VN, Varvel D. Acquisition-time image quality control in digital dermatoscopy of skin lesions. Comput Med Imaging Graph 2001;25:495-9. 87. Gutkowicz-Krusin D, Elbaum M, Jacobs A, Keem S, Kopf AW, Kamino H, et al. Precision of automatic measurements of pigmented skin lesion parameters with a MelaFind(TM) mul- tispectral digital dermoscope. Melanoma Res 2000;10:563-70. 88. Menzies SW. Automated epiluminescence microscopy: human vs machine in the diagnosis of melanoma. Arch Dermatol 1999;135:1538-40. 89. Moncrieff M, Cotton S, Claridge E, Hall P. Spectrophotometric intracutaneous analysis: a new technique for imaging pig- mented skin lesions. Br J Dermatol 2002;146:448-57. 90. Murali A, Stoecker WV, Moss RH. Detection of solid pigment in dermatoscopy images using texture analysis. Skin Res Technol 2000;6:193-8. 91. Rubegni P, Ferrari A, Cevenini G, Piccolo D, Burroni M, Perotti R, et al. Differentiation between pigmented Spitz naevus and melanoma by digital dermoscopy and stepwise logistic discriminant analysis. Melanoma Res 2001;11:37-44. 92. Schmid P. Segmentation of digitized dermatoscopic images by two-dimensional color clustering. IEEE Trans Med Imaging 1999;18:164-71. 93. Smolle J. Computer recognition of skin structures using discriminantand clusteranalysis. Skin Res Technol2000;6:58-63. 94. Stoecker WV, Moss RH. Digital imaging in dermatology. Comput Med Imaging Graph 1992;16:145-50. J AM ACAD DERMATOL JANUARY 2005 120 Braun et al
  13. 13. 95. Braun RP, Meier M, Pelloni F, Ramelet AA, Schilling M, Tapernoux B, et al. Teledermatoscopy in Switzerland: a pre- liminary evaluation. J Am Acad Dermatol 2000;42:770-5. 96. Piccolo D, Smolle J, Argenziano G, Wolf IH, Braun R, Cerroni L, et al. Teledermoscopy—results of a multicentre study on 43 pigmented skin lesions. J Telemed Telecare 2000;6:132-7. 97. Piccolo D, Smolle J, Wolf IH, Peris K, Hofmann-Wellenhof R, Dell’Eva G, et al. Face-to-face diagnosis vs telediagnosis of pigmented skin tumors: a teledermoscopic study. Arch Der- matol 1999;135:1467-71. 98. Provost N, Kopf AW, Rabinovitz HS, Stolz W, DeDavid M, Wasti Q, et al. Comparison of conventional photographs and tele- phonically transmitted compressed digitized images of mela- nomas and dysplastic nevi. Dermatology 1998;196:299-304. ADDITIONAL READING 1. Argenziano G, Soyer HP, De Giorgi V, Piccolo D, Carli P, et al. Dermoscopy: A tutorial. 1st ed. Milan: EDRA; 2000. 2. Menzies SW, Crotty KA, Ingvar C, McCarthy WH. An atlas of surface microscopy of pigmented lesions. Sydney: McGraw-Hill Company; 1996. 3. Stolz W, Braun-Falco O, Bilek P, Landthaler M, Burgdorf WHC, Cognetta AB. Color atlas of dermatoscopy. 2nd ed. Berlin: Blackwell Wessenschafts-Verlag; 2002. 4. Soyer HP, Argenziano G, Chimenti S, Rabinovitz HS, Stolz W, Kopf AW, et al. Dermoscopy of pigmented lesions. Milan: EDRA; 2001. 5. Rabinovitz HS, Cognetta AB. Dermatologic clinics. Philadelphia (PA): WB Saunders; 2001. 6. Johr R, Soyer HP, Argenziano G, Hofmann-Wellenhof R, Scalvenzi M. Dermoscopy: The essentials. London: Mosby; 2004. 8. Marghoob AA, Braun RP, Kopf AW. Atlas of dermoscopy. London: Taylor & Francis; 2005. 9. Malvehy J, Puig S. Principles of dermoscopy. Barcelona: CEGE Editors; 2002. J AM ACAD DERMATOL VOLUME 52, NUMBER 1 Braun et al 121

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