Dermoscopy of pigmented skin lesionsDocument Transcript
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.)
I n the last two decades a rising incidence of HISTORY OF DERMOSCOPY
malignant melanoma has been observed.1-7 Skin surface microscopy started in 1663 with
Because of a lack of adequate therapies for Kolhaus who investigated the small vessels in the
metastatic melanoma, the best treatment currently nailfold with the help of a microscope.11,19 In 1878,
is still early diagnosis and prompt surgical excision of Abbe described the use of immersion oil in light
the primary cancer.5,7 Dermoscopy (also known as microscopy 20 and this principle was transferred to
epiluminescence microscopy, dermatoscopy, and skin surface microscopy by the German dermatolo-
amplified surface microscopy) is an in vivo method, gist, Unna, in 1893.21 He introduced the term
that has been reported to be a useful tool for the early ‘‘diascopy’’ and described the use of immersion oil
recognition of malignant melanoma.8-11 The perfor- and a glass spatula for the interpretation of lichen
mance of dermoscopy has been investigated by planus and for the evaluation of the infiltrate in lupus
many authors. Its use increases diagnostic accuracy erythematosus. The term ‘‘dermatoscopy’’ was in-
between 5% and 30% over clinical visual inspection, troduced in 1920 by the German dermatologist
depending on the type of skin lesion and experience Johann Saphier who published a series of commu-
of the physician.12-16 This was confirmed by recent nications using a new diagnostic tool resembling
evidence-based publications and based on a meta- a binocular microscope with a built-in light source
analysis of the literature.17,18 This article is a review of for the examination of the skin.22-25 He used this new
the principles of dermoscopy as well as recent tool in various indications and did some interesting
technological developments. 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
From the Pigmented Skin Lesion Unit, Department of Dermatol- Goldman in the 1950s. He published a series of
ogy, University Hospital Genevaa; Skin and Cancer Associates,
Plantation, Fla, and Department of Dermatology, University of
interesting articles on new devices on what he called
Miami School of Medicineb; and The Ronald O. Perelman ‘‘Dermoscopy.’’26-29 He was the first dermatologist to
Department of Dermatology, New York University School of use this new technique for the evaluation of pig-
Medicine.c mented skin lesions. In 1971, Rona MacKie30 clearly
Funding sources: The work of Dr Braun has been supported by the identified, for the first time, the advantage of surface
Swiss Cancer League. Dr Kopf has the following funding
sources: The Ronald O. Perelman Department of Dermatology, microscopy for the improvement of preoperative
New York University School of Medicine, Joseph H. Hazen diagnosis of pigmented skin lesions and for the
Foundation, Mary and Emanuel Rosenthal Foundation, Kaplan differential diagnosis of benign versus malignant
Comprehensive Cancer Center (Cancer Center Support Core lesions. These investigations were continued mainly
Grant No. 5P30-CA-16087), Blair O. Rogers Medical Research in Europe by several Austrian and German groups.
Fund, The Rahr Family Foundation, and Stravros S. Niarchos
Foundation Fund of the Skin Cancer Foundation. The first Consensus Conference on Skin Surface
Conflict of interest: None. Microscopy was held in 1989 in Hamburg31 and the
Accepted for publication November 9, 2001. Consensus Netmeeting on Dermoscopy, which was
Reprint requests: R. P. Braun, MD, Department of Dermatology, held in 2001 in Rome32 (http://www.dermoscopy.
University Hospital Geneva, 24, rue Micheli-du-Crest, CH—
org), was the first international meeting of its
1211Geneva 14, Switzerland. E-mail: email@example.com.
kind. Today dermoscopy has become a routine
ª 2005 by the American Academy of Dermatology, Inc. technique in Europe and is gaining acceptance in
doi:10.1016/j.jaad.2001.11.001 other countries.
110 Braun et al J AM ACAD DERMATOL
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
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,
Not in the holes of the pigment network Bowen’s disease, etc (short vertical height)
Hairpin vessels Long capillary loops of thicker tumors at the Thick melanomas
Whitish halo in tumors with keratin SCC keratoacanthoma, seborrheic keratosis
BCC, Basal cell carcinoma; SCC, squamous cell carcinoma.
PHYSICAL ASPECTS DERMOSCOPIC CRITERIA
Light is either reﬂected, dispersed, or absorbed by Colors
the stratum corneum because of its refraction index The use of dermoscopy allows the identiﬁcation
and its optical density, which is different from air.33 of many different structures and colors, not seen by
Thus, deeper underlying structures cannot be ade- the naked eye.
quately visualized. However, when various immer- Colors play an important role in dermoscopy.
sion liquids are used, they render the skin surface Common colors are light brown, dark brown, black,
translucent and reduce the reflection, so that un- blue, blue-gray, red, yellow, and white. The most
derlying structures are readily visible. The applica- important chromophore in melanocytic neoplasms is
tion of a glass plate flattens the skin surface and melanin.11,13,36 The color of melanin essentially
provides an even surface. Optical magnification is depends on its localization in the skin. The color
used for examination. Taken together, these optical black is due to melanin located in the stratum
means allow the visualization of certain epidermal, corneum and the upper epidermis, light to dark
dermo-epidermal, and dermal structures. 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
MATERIAL FOR DERMOSCOPY melanin localized within the deeper parts of the skin
Dermoscopy requires optical magniﬁcation and because the portions of visible light with shorter
liquid immersion. This can be performed with very wavelengths (blue-violet end of spectrum) are more
simple, inexpensive equipment.34,35 Specially de- dispersed than portions with longer wavelengths
signed handheld devices with 10 to 20 times magni- (red end of visible spectrum).37,38 The color red is
fication are commercially available (Dermatoscope associated with an increased number or dilatation of
[Heine AG]; DermoGenius Basic [Rodenstock blood vessels, trauma, or neovascularization. The
Prazisionsoptik]; Episcope [Welch-Allyn]; DermLite color white is often caused by regression and/or
[3Gen, LLC]). Photographic documentation can be scarring.11
performed with a dermoscopic attachment to a stan-
dard camera (Dermaphot, Heine, AG) which can be
used also with some digital cameras. Most recently, Dermoscopic structures
digital cameras have been designed that are attached In this context we will use the nomenclature as
to computers. This allows easy storage, retrieval, and proposed by the recent Consensus Netmeeting (held
follow-up of pigmented skin lesions. For dermatol- in Rome in 2001) with some revisions32:
ogists with less experience in dermoscopy, some of Pigment network. The pigment network is
the systems may offer the possibility of computer- a grid-like (honeycomb-like) network consisting
assisted diagnosis for malignant melanoma or for of pigmented ‘‘lines’’ and hypopigmented
consulting an expert through telemedicine. ‘‘holes.’’11,13,36,37,39 The anatomic basis of the
J AM ACAD DERMATOL Braun et al 111
VOLUME 52, NUMBER 1
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
pigment network is either melanin pigment in Fig 2. Algorithm for the determination of melanocytic
keratinocytes, or in melanocytes along the dermoe- versus nonmelanocytic lesions according to the proposi-
tion of the Board of the Consensus Netmeeting. Adapted
pidermal junction.40 The reticulation (network) rep-
from Argenziano G et al. J Am Acad Dermatol 2003;48:
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- usually in the lower epidermis, at the dermoepider-
mis.13,36,37 mal junction, or in the papillary dermis.11,37,42,46
The pigment network can be either typical or Both dots and globules may occur in benign as
atypical. A typical network is relatively uniform, well as in malignant melanocytic proliferations. In
regularly meshed, homogeneous in color, and usu- benign lesions, they are rather regular in size and
ally thinning out at the periphery.36,39,44 An atypical shape and quite evenly distributed (frequently in the
network is nonuniform, with darker and/or broad- center of a lesion).32,36 In melanomas they tend to
ened lines and ‘‘holes’’ that are heterogeneous in vary in size and shape and are frequently found in
area and shape. The lines are often hyperpigmented the periphery of lesions.32,36,48
and may end abruptly at the periphery.36,39,44 Branched streaks. Branched streaks are an
If the rete ridges are short or less pigmented, the expression of an altered pigmented network in which
pigment network may not be visible. Areas devoid of the network becomes disrupted or broken up.11,32,45
any network (but without signs of regression) are Their pathological correlations are remnants of pig-
called ‘‘structureless areas.’’11,45 mented rete ridges and bridging nests of melanocytic
Dots. Dots are small, round structures less than cells within the epidermis and papillary dermis.11
0.1 mm in diameter, which may be black, brown, Radial streaming. Radial streaming appears as
gray, or blue-gray.11,13,32,36 Black dots are caused by radially and asymmetrically arranged, parallel linear
pigment accumulation in the stratum corneum and in extensions at the periphery of a lesion.13,49 Histo-
the upper part of the epidermis.11,37,42,46 Brown dots logically, they represent confluent pigmented junc-
represent focal melanin accumulations at the der- tional nests of pigmented melanocytes.13,36
moepidermal junction.47 Gray-blue granules (pep- Pseudopods. Pseudopods represent ﬁngerlike
pering) are caused by tiny melanin structures in the projections of dark pigment (brown to black) at the
papillary dermis. Gray-blue or blue granules are due periphery of the lesion.13,49,50 They may have small
to loose melanin, fine melanin particles or melanin knobs at their tips, and are either connected to the
‘‘dust’’ in melanophages or free in the deep papillary pigment network or directly connected to the tumor
or reticular dermis.11,37,42,46 body.13,50 They correspond as well to intraepidermal
Globules. Globules are symmetrical, round to or junctional confluent radial nests of melano-
oval, well-demarcated structures that may be brown, cytes.13,50 Menzies et al49 found pseudopods to be
black, or red.11,13,32,36 They have a diameter which is one of the most specific features of superficial
usually larger than 0.1 mm and correspond to nests spreading melanoma.
of pigmented benign or malignant melanocytes, Streaks. ‘‘Streaks’’ is a term used by some
clumps of melanin, and/or melanophages situated authors interchangeably with radial streaming or
112 Braun et al J AM ACAD DERMATOL
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 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).
Fig 6. A, Macroscopic picture of a seborrheic keratosis. B, Dermoscopy of A shows comedo-
like openings and multiple milia-like cysts.
J AM ACAD DERMATOL Braun et al 113
VOLUME 52, NUMBER 1
Fig 7. A, Macroscopic picture of a basal cell carcinoma. B, Dermoscopy of A shows maple
leafelike areas, ovoid nests, and arborized telangiectasia.
Fig 8. A, Macroscopic picture of a basal cell carcinoma. B, Dermoscopy of A shows multiple
spoke wheel areas.
Fig 9. A, Macroscopic picture of an angioma. B, Dermoscopy of A shows red lagoons.
pseudopods. This is because both these structures melanin pigment localized throughout the epidermis
have the same histopathological correlation.11,37,42,46 and/or dermis visually obscuring the underlying
Streaks can be irregular, when they are unevenly structures.41-43,46
distributed (malignant melanoma), or regular (sym- Regression pattern. Regression appears as
metrical radial arrangement over the entire lesion). white scar-like depigmentation (lighter than the sur-
The latter is particularly found in the pigmented rounding skin) or ‘‘peppering’’ (speckled multiple
spindle cell nevi (Reed’s nevi).51-53 blue-gray granules within a hypopigmented area).
Structureless areas. Structureless areas repre- Histologically, regression shows ﬁbrosis, loss of pig-
sent areas devoid of any discernible structures (eg, mentation, epidermal thinning, effacement of the rete
globules, network). They tend to be hypopig- ridges, and melanin granules free in the dermis or in
mented, which is due to the absence of pigment or melanophages scattered in the papillary dermis.43,46
diminution of pigment intensity within a pigmented Blue-white veil. Blue-white veil is an irregu-
skin lesion.11 lar, indistinct, conﬂuent blue pigmentation with
Blotches. A blotch (also called black lamella by an overlying white, ground-glass haze.13,32 The
some authors) is caused by a large concentration of pigmentation cannot occupy the entire lesion.
114 Braun et al J AM ACAD DERMATOL
Table II. Pattern analysis according to Pehamberger et al39 (modified)
Lentigo simplex Junctional nevus Compound nevus Dermal nevus Blue nevus
Regular pigment Regular pigment Regular pigment No criteria for Steel-blue areas
network without network without network without melanocytic lesion
interruptions interruptions interruptions
Regular border, thins Regular border, thins Regular border, thins No pigment network No pigment network
out at periphery out at periphery out at periphery
Black dots over grids Heterogeneous holes Heterogeneous holes Brown globules lll-defined
of pigment of pigment of pigment
network network network
Brown-black globules Brown globules Brown globules Homogeneous White veils are
at center of the colors possible
Homogeneous colors Homogeneous colors Symmetric papular ‘‘Pseudonetwork’’ No pseudonetwork
All criteria for ‘‘Comma’’-shaped
melanocytic lesion blood vessels
Histopathologically this corresponds to an aggrega- References 8, 11, 13, 32, 36, 37, 49, 55, 60-64.
tion of heavily pigmented cells or melanin in the Fissures and ridges (‘‘brain-like appear-
dermis (blue color) in combination with a compact ance’’). Fissures are irregular, linear keratin-ﬁlled
orthokeratosis.13,32,36,43,46,54 depressions, commonly seen in seborrheic kerato-
Vascular pattern. Pigmented skin lesions may ses.63 They may also be seen in melanocytic nevi
have dermoscopically visible vascular patterns, with congenital patterns and in some dermal mela-
which include ‘‘comma vessels,’’ ‘‘point vessels,’’ nocytic nevi. Multiple fissures might give a ‘‘brain-
‘‘tree-like vessels,’’ ‘‘wreath-like vessels,’’ and ‘‘hair- like appearance’’ to the lesion.32,36,63,65 This pattern
pin-like vessels’’ (Table I).55-57 Atypical vascular has also been named ‘‘gyri and sulci’’ or ‘‘mountain
patterns may include linear, dotted, or globular red and valley pattern’’ by some authors.11
structures irregularly distributed within the le- Fingerprint-like structures. Some ﬂat sebor-
sion.32,36,58,59 Some of the vascular patterns may be rheic keratoses (also known as solar lentigines) can
caused by neovascularization. For the evaluation of show tiny ridges running parallel and producing
vascular patterns, there has to be as little pressure as a pattern that resembles ﬁngerprints.11,32,65,66
possible on the lesion during examination because Moth-eaten border. Some ﬂat seborrheic kera-
otherwise the vessels are simply compressed and toses (mainly on the face) have a concave border
will not be visible. The use of ultrasound gel for so that the pigment ends with a curved structure,
immersion helps to reduce the pressure necessary which has been compared to a moth-eaten gar-
for the best evaluation of the skin lesion.57 ment.11,13,32,63,65,66
Milia-like cysts. Milia-like cysts are round whit- Leaf-like areas. Leaf-like areas (maple leafelike
ish or yellowish structures which are mainly seen in areas) are seen as brown to gray-blue discrete
seborrheic keratosis.* They correspond to intraepi- bulbous blobs, sometimes forming a leaf-like pat-
dermal keratin-ﬁlled cysts and may also be seen in tern.* Their distribution reminds one of the shape
congenital nevi as well as in some papillomatous of ﬁnger pads. In absence of a pigment network,
melanocytic nevi. At times, milia-like cysts are they are suggestive of pigmented basal cell car-
pigmented, and thus, can resemble globules. cinoma.11,32,67
*References 8, 11, 13, 32, 36, 37, 49, 55, 60-63. *References 8, 9, 11, 13, 32, 36, 37, 39, 55, 65,
Comedo-like openings (crypts, pseudofollic- 67, 68.
ular openings). Comedo-like openings (with Spoke wheelelike structures. Spoke wheele
‘‘blackhead-like plugs’’) are mainly seen in sebor- like structures are well-circumscribed, brown to
rheic keratoses or in some rare cases in papilloma- gray-blue-brown, radial projections meeting at
tous melanocytic nevi.y The keratin-filled invaginations a darker brown central hub.11,32,67 In the absence
of the epidermis correspond to the comedo-like of a pigment network, they are highly suggestive of
structures histopathologically. basal cell carcinoma.
J AM ACAD DERMATOL Braun et al 115
VOLUME 52, NUMBER 1
Table II. Cont’d
Malignant melanoma Atypical (Clark) nevus Angioma Seborrheic keratosis Pigmented BCC
Heterogeneous Irregular pigment No features of No features for No features for
(colors and network with melanocytic lesion melanocytic lesion melanocytic lesion
Asymmetry (colors Heterogeneous holes No pigment network Pigment network Maple-leafelike
and structures) usually absent pigmentation
Irregular pigment Irregular border Red, red-blue, or Milia-like cysts Telangiectasia
network red-black lagoons,
( globules, saccules)
Irregular border with Heterogeneity of Abrupt border cut-off Pseudofollicular Tree-like blood
abrupt peripheral colors openings, vessels
Structureless areas Gray-white veil Rough surface ‘‘Dirty’’ gray-brown to
Gray-blue or red-rose Absence of primary Abrupt border cut-off
veils criteria for
Red Opaque gray-brown
Point and hairpin
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
Differential structures 1 point for every structure: 1-5 0.5 0.5-2.5
Total score range: 1.0-8.9
Large blue-gray ovoid nests. Ovoid nests are Multiple blue-gray globules. Multiple blue-
large, well-circumscribed, conﬂuent or near-con- gray globules are round, well-circumscribed struc-
ﬂuent, pigmented ovoid areas, larger than glob- tures that are, in the absence of a pigment network,
ules, and not intimately connected to a pigmented highly suggestive of basal cell carcinoma.11,32,67
tumor body.11,32,67 When a network is absent, They have to be differentiated from multiple blue-
ovoid nests are highly suggestive of basal cell gray dots (which correspond to melanophages and
carcinoma. melanin dust).
116 Braun et al J AM ACAD DERMATOL
Table IV. The 7-point checklist according to Table V. ‘‘The Menzies Method’’ according to
Argenziano et al44 Menzies et al13,49
Criteria 7-point score Negative features
Major criteria Point and axial symmetry of pigmentation
Atypical pigment network 2 Presence of a single color
Blue-white veil 2 Positive features
Atypical vascular pattern 2 Blue-white veil
Minor criteria Multiple brown dots
Irregular streaks 1 Pseudopods
Irregular pigmentation 1 Radial streaming
Irregular dots/globules 1 Scar-like depigmentation
Regression structures 1 Peripheral black dots-globules
Multiple colors (5 or 6)
Multiple blue/gray dots
DIFFERENTIAL DIAGNOSIS OF
PIGMENTED LESIONS OF THE SKIN
There are many publications on the subject of the Once the lesion is identiﬁed to be of melanocytic
differential diagnosis of pigmented lesions of the origin, the decision has to be made if the melanocytic
skin. The 5 algorithms most commonly used are lesion is benign, suspect, or malignant. To accom-
pattern analysis8,39,62; the ABCD rule of dermo- plish this, 4 different approaches are the most
scopy11,45,70; the 7-point checklist32,36,44; the commonly used.
Menzies method13,32,49; and the revised pattern
analysis.71 Pattern analysis (Pehamberger et al)
The Board of the Consensus Netmeeting agreed Pattern recognition has historically been used by
on a two-step procedure for the classiﬁcation of clinicians and histopathologists to differentiate be-
pigmented lesions of the skin (Fig 1). A similar nign lesions from malignant neoplasms. A similar
approach has been proposed by other authors in process has been found useful with dermoscopy,
the past. and has been termed ‘‘pattern analysis.’’ It allows
The ﬁrst step is the differentiation between distinction between benign and malignant growth
a melanocytic and a nonmelanocytic lesion. For features. It was described by Pehamberger and
this decision, the algorithm in Fig 2 is used. colleagues based on the analysis of more than 7000
Are aggregated globules, pigment network, pigmented skin lesions.8,39,62 Table II shows the
branched streaks (Fig 3), homogeneous blue pig- typical patterns of some common, pigmented skin
mentation (blue nevus: Fig 4), or a parallel pattern lesions using pattern analysis.
(palms, soles, and mucosa) visible? If this is the case,
the lesion should be considered as a melanocytic ABCD rule of dermatoscopy (Stolz et al)
lesion (Fig 3). If not, the lesion should be evaluated The ABCD rule of dermatoscopy, described by
for the presence of comedo-like plugs, multiple Stolz et al in 1993 was based on an analysis of 157
milia-like cysts, and comedo-like openings, irregular pigmented skin lesions.11,70 The complete ABCD
crypts, light brown fingerprint-like structures, or rule is explained in Table III.
‘‘fissures and ridges’’ (brain-like appearance) pat- For the evaluation of asymmetry, the lesion is
tern. If so, the lesion is suggestive of a seborrheic divided into 4 segments (2 perpendicular axes). The
keratosis (Figs 5 and 6). If not, the lesion has to be axes are oriented so that the lowest asymmetry is
evaluated for the presence of arborizing blood obtained. For asymmetry in both axes, a value of 2 is
vessels (telangiectasia), leaf-like areas, large blue- obtained. To calculate the subscore, the value of each
gray ovoid nests, multiple blue-gray globules, spoke ABCD category has to be multiplied by the corre-
wheel areas, or ulceration. If present, the lesion is sponding weight factor. To obtain the total score
suggestive of basal cell carcinoma (Figs 7 and 8). If value, the different ABCD subscores have to be
not, one has to look for red or red-blue (to black) added.
lagoons. If these structures are present, the lesion The total score ranges from 1 to 8.9. A lesion with
should be considered a hemangioma (Fig 9) or an a total score greater than 5.45 should be considered
angiokeratoma. If all the preceding questions were as melanoma. A lesion with a total score of 4.75
answered with ‘‘no,’’ the lesion should still be or less can be considered as benign. A lesion with
considered to be a melanocytic lesion. a score value between 4.75 and 5.45 should be
J AM ACAD DERMATOL Braun et al 117
VOLUME 52, NUMBER 1
Table VI. Pattern of benign and malignant lesions
Dots Centrally located or situated right on the Unevenly distributed and scattered focally at
network the periphery
Globules Uniform in size, shape, and color, symmetrically Globules that are unevenly distributed and
located at the periphery, centrally located, or when reddish are highly suggestive of
uniform throughout the lesion as in a melanoma
Streaks Radial streaming or pseudopods tend to be Radial streaming or pseudopods tend to be
symmetrical and uniform at the periphery 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 Asymmetrically located or there are often
hyperpigmented area that extends almost to multiple asymmetrical blotches
periphery of the lesion
Network Typical network that consists of light to dark Atypical network that may be nonuniform with
uniform pigmented lines and black/brown or gray thickened lines and
hypopigmented holes holes of different sizes and shapes
Network borders Either fades into the periphery or is Focally sharp
considered ‘‘suspicious’’ and should therefore be The face has a very particular anatomic architec-
monitored closely or removed.11,70 ture especially concerning the dermoepidermal
junction where rete ridges are shorter. That is why
7-point checklist facial lesions often do not exhibit a regular pigment
In 1998 Argenziano and colleagues described a 7- network. Dermoscopy shows a broadened pigment
point checklist based on the analysis of 342 pig- reticulation which is called a ‘‘pseudonetwork.’’ This
mented skin lesions.32,36,44 They distinguish 3 major does not correspond to the projection of pigmented
criteria and 4 minor criteria (Table IV). Each major rete ridges. It is due to a homogeneous pigmentation
criterion has a score of 2 points while each minor which is interrupted by the surface openings of the
criterion has a score of 1 point. A minimum total adnexal structures.11,66,73
score of 3 is required for the diagnosis of malignant The differential diagnosis of a pseudonetwork is
melanoma. solar lentigo, seborrheic keratosis, lentigo simplex,
melanoma in situ, lichen planuselike keratosis, and
Menzies method pigmented actinic keratosis.11,66,73 These lesions
In the Menzies method13,32,49 for diagnosing are often difficult to distinguish dermoscopically.
melanoma, both of the following negative features However, when there are multiple colors and
must not be found: a single color (tan, dark brown, a broadened, thickened, and irregular ‘‘pseudonet-
gray, black, blue, and red, but white is not consid- work,’’ melanoma is often the diagnosis suggested.
ered) and ‘‘point and axial symmetry of pigmenta- Other, more specific characteristics include an ‘‘an-
tion’’ (refers to pattern symmetry around any axis nular granular’’ or ‘‘rhomboidal pattern.’’11,66,73
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 Revised pattern analysis
found (Table V). The overall general appearance of color, architec-
tural order, symmetry of pattern, and homogeneity
Exceptions to the algorithms (CASH) are important components in distinguishing
The ABCD rule is not applicable for pigmented these two groups. Benign melanocytic lesions tend
lesions on the palms, soles, or face.11 Palms and soles to have few colors, architectural order, symmetry of
have a particular anatomy which is characterized by pattern, or homogeneity. Malignant melanoma often
marked orthokeratosis and the presence of sulci and has many colors and much architectural disorder,
gyri. The sweat ducts join the surface at the summits asymmetry of pattern, and heterogeneity.
of the gyri.11,32 A classification of 10 different The reticular pattern or network pattern is the
dermoscopy patterns on the palms and soles has most common global feature in melanocytic lesions.
been proposed by Saida et al.72 This pattern represents the junctional component
118 Braun et al J AM ACAD DERMATOL
of a melanocytic nevus (Clark nevus, dysplastic with dermoscopy has been shown to depend on the
nevus).32,36,71 experience of the dermatologist, such objective
Another pattern is the so-called globular pattern. systems might help less-experienced dermatologists
It is characterized by the presence of numerous in the future.
‘‘aggregated globules.’’ This pattern is commonly Another expanding ﬁeld is teledermoscopy. At
seen in a congenital nevus, superficial type.32,36,71 the beginning of the digital dermoscopic era, tele-
The cobblestone pattern is very similar to the dermoscopy was used between experts to exchange
globular pattern but is composed of closer aggre- difﬁcult or interesting images. The development of
gated globules, which are somehow angulated, re- new electronic media and the evolution of the
sembling cobblestones. Internet will have an important impact as the in-
The homogeneous pattern appears as diffuse frastructure becomes available to almost everyone,
pigmentation, which might be brown, gray-blue, and the exchange is now easy to perform. Recent
gray-black, or reddish black.32,36,71 No pigment studies were able to show the feasibility and impor-
network or any other distinctive dermoscopy struc- tance of teledermoscopy.95-98 This was recently used
ture is found. An example is the homogeneous steel- in a Consensus Netmeeting on Dermoscopy held in
blue color seen in blue nevi. Rome during the first World57,69 Congress on Der-
The so-called starburst pattern is characterized by moscopy (http://www.dermoscopy.org).32
the presence of streaks in a radial arrangement,
We thank Dr G. Argenziano, Dr J. Kreusch, Professor S.
which is visible at the periphery of the lesion.32,36,71 Menzies, Professor H. Pehamberger, and Professor W.
This pattern is commonly seen in Reed nevi or Spitz Stolz for their suggestions and their permission for the
nevi. reproductions. We also thank Dr S. Rabinovitz for her help
The parallel pattern is exclusively found on the during the entire editing process and for her valuable
palms and soles due to the particular anatomy of suggestions.
The combination of 3 or more distinctive dermo-
scopic structures (ie, network, dots, and globules as REFERENCES
well diffuse areas of hyperpigmentation and hypo- 1. Rigel DS, Friedman RJ, Kopf AW. The incidence of malignant
melanoma in the United States: Issues as we approach the
pigmentation) within a given lesion is called multi- 21st century. J Am Acad Dermatol 1996;34:839-47.
component pattern.32,36,71 This pattern is highly 2. Rigel DS, Friedman RJ, Kopf AW. Lifetime risk for development
suggestive of melanoma, but might be observed in of skin cancer in the U.S. population: current estimate is now 1
some cases in acquired melanocytic nevi and con- in 5. J Am Acad Dermatol 1996;35:1012-3.
genital nevi. 3. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics,
1999. CA Cancer J Clin 1999;49:8-31.
The term ‘‘lesions with indeterminate patterns’’ 4. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics,
are dermoscopic patterns that can be seen in both 1998. CA Cancer J Clin 1998;48:6-29.
benign and malignant pigmented lesions. Clinically 5. Rigel DS, Carucci JA. Malignant melanoma: prevention, early
and dermoscopically, one cannot make a distinction detection, and treatment in the 21st century. CA Cancer J Clin
between whether they are melanomas or atypical 2000;50:215-36.
6. Burton RC. Malignant melanoma in the year 2000. CA Cancer
nevi. J Clin 2000;50:209-13.
In addition to the global features already men- 7. Rigel DS. Malignant melanoma: perspectives on incidence and
tioned, the local features (dermoscopic structures its effects on awareness, diagnosis, and treatment. CA Cancer
such as the pigment network, dots, and globules, etc) J Clin 1996;46:195-8.
are important to evaluate melanocytic lesions 8. Pehamberger H, Binder M, Steiner A, Wolff K. In vivo
epiluminescence microscopy: improvement of early diagnosis
(Table VI). of melanoma. J Invest Dermatol 1993;100:356S-62S.
9. Soyer HP, Argenziano G, Chimenti S, Ruocco V. Dermoscopy of
PERSPECTIVES pigmented skin lesions. Eur J Dermatol 2001;11:270-6.
Because computer hardware has become user- 10. Soyer HP, Argenziano G, Talamini R, Chimenti S. Is dermoscopy
useful for the diagnosis of melanoma? Arch Dermatol
friendly and more affordable, digital dermoscopy
will become more integrated into the clinical setting. 11. Stolz W, Braun-Falco O, Bilek P, Landthaler M, Burgdorf WHC,
The currently available digital dermoscopic systems Cognetta AB. Color alas of drmatoscopy. 2nd ed. Berlin:
already have an acceptable picture quality which Blackwell Wissenschafts-Verlag; 2002.
comes close to a photograph.74 Digital images offer 12. Mayer J. Systematic review of the diagnostic accuracy of
dermatoscopy in detecting malignant melanoma. Med J Aust
the possibility of computer storage and retrieval of
dermoscopic images and patient data.48,75-78 Some 13. Menzies SW, Crotty KA, Ingvar C, McCarthy WH. An atlas of
systems even offer the potential of ‘‘computer- surface microscopy of pigmented skin lesions. Sydney:
assisted diagnosis.’’79-94 Because diagnostic accuracy McGraw-Hill Book Company; 2003.
J AM ACAD DERMATOL Braun et al 119
VOLUME 52, NUMBER 1
14. Binder M, Schwarz M, Winkler A, Steiner A, Kaider A, Wolff K, epiluminescence microscopy. Grading protocol and atlas.
et al. Epiluminescence microscopy. A useful tool for the di- Arch Dermatol 1993;129:157-74.
agnosis of pigmented skin lesions for formally trained 38. Reisfeld PL. Blue in the skin. J Am Acad Dermatol 2000;42:
dermatologists. Arch Dermatol 1995;131:286-91. 597-605.
15. Binder M, Puespoeck-Schwarz M, Steiner A, Kittler H, Muellner 39. Pehamberger H, Steiner A, Wolff K. In vivo epiluminescence
M, Wolff K, et al. Epiluminescence microscopy of small microscopy of pigmented skin lesions. I. Pattern analysis of
pigmented skin lesions: short-term formal training improves pigmented skin lesions. J Am Acad Dermatol 1987;17:571-83.
the diagnostic performance of dermatologists. J Am Acad 40. Krischer J, Skaria A, Guillod J, Lemonnier E, Salomon D, Braun
Dermatol 1997;36:197-202. R, et al. Epiluminescent light microscopy of melanocytic
16. Westerhoff K, McCarthy WH, Menzies SW. Increase in the lesions after dermoepidermal split. Dermatology 1997;
sensitivity for melanoma diagnosis by primary care physicians 195:108-11.
using skin surface microscopy. Br J Dermatol 2000;143: 41. Massi D, De Giorgi V, Soyer HP. Histopathologic correlates of
1016-20. dermoscopic criteria. Dermatol Clin 2001;19:259-68.
17. Bafounta ML, Beauchet A, Aegerter P, Saiag P. Is dermoscopy 42. Soyer HP, Kenet RO, Wolf IH, Kenet BJ, Cerroni L. Clinicopath-
(epiluminescence microscopy) useful for the diagnosis of ological correlation of pigmented skin lesions using dermo-
melanoma? Results of a meta-analysis using techniques scopy. Eur J Dermatol 2000;10:22-8.
adapted to the evaluation of diagnostic tests. Arch Dermatol 43. Yadav S, Vossaert KA, Kopf AW, Silverman M, Grin-Jorgensen
2001;137:1343-50. C. Histopathologic correlates of structures seen on dermo-
18. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic scopy (epiluminescence microscopy). Am J Dermatopathol
accuracy of dermoscopy. Lancet Oncol 2002;3:159-65. 1993;15:297-305.
19. Gilje O, O’Leary PA, Baldes EY. Capillary microscopic examina- 44. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Sammarco E,
tion in skin siease. Arch Dermatol 1958;68:136-45. Delfino M. Epiluminescence microscopy for the diagnosis of
20. Diepgen P. Geschichte der Medizin. Berlin: De Gruyter; 1965. doubtful melanocytic skin lesions. Comparison of the ABCD
21. Unna P. Die Diaskopie der Hautkrankheiten. Berl Klin Wochen rule of dermatoscopy and a new 7-point checklist based on
1885;42:1016-21. pattern analysis. Arch Dermatol 1998;134:1563-70.
22. Saphier J. Die Dermatoskopie. I. Mitteilung. Arch Dermatol 45. Nachbar F, Stolz W, Merkle T, Cognetta AB, Vogt T, Landthaler
Syphiol 1920;128:1-19. M, et al. The ABCD rule of dermatoscopy: high prospective
23. Saphier J. Die Dermatoskopie. II. Mitteilung. Arch Dermatol value in the diagnosis of doubtful melanocytic skin lesions.
Syphiol 1921;132:69-86. J Am Acad Dermatol 1994;30:551-9.
24. Saphier J. Die Dermatoskopie. IV. Mitteilung. Arch Dermatol 46. ¨
Soyer HP, Smolle J, Hodl S, Pachernegg H, Kerl H. Surface
Syphiol 1921;136:149-58. microscopy: a new approach to the diagnosis of cutaneous
25. Saphier J. Die Dermatoskopie. III. Mitteilung. Arch Dermatol pigmented tumors. Am J Dermatopathol 1989;11:1-10.
Syphiol 2002;134:314-22. 47. Guillod JF, Skaria AM, Salomon D, Saurat JH. Epiluminescence
26. Goldman L. Some investigative studies of pigmented nevi videomicroscopy: black dots and brown globules revisited by
with cutaneous microscopy. J Invest Dermatol 1951;16:407-26. stripping the stratum corneum. J Am Acad Dermatol
27. Goldman L. Clinical studies in microscopy of the skin at 1997;36:371-7.
moderate magnification. Arch Dermatol 1957;75:345-60. 48. Kittler H, Seltenheim M, Dawid M, Pehamberger H, Wolff K,
28. Goldman L. A simple portable skin microscope for surface Binder M. Frequency and characteristics of enlarging common
microscopy. Arch Dermatol 1958;78:246-7. melanocytic nevi. Arch Dermatol 2000;136:316-20.
29. Goldman L. Direct skin microscopy as an aid in the early 49. Menzies SW, Ingvar C, McCarthy WH. A sensitivity and
diagnosis of precancer and cancer of the skin in the elderly. specificity analysis of the surface microscopy features of
J Am Geriatr Soc 1980;28:337-40. invasive melanoma. Melanoma Res 1996;6:55-62.
30. MacKie RM. An aid to the preoperative assessment of 50. Menzies SW, Crotty KA, McCarthy WH. The morphologic
pigmented lesions of the skin. Br J Dermatol 1971;85:232-8. criteria of the pseudopod in surface microscopy. Arch
31. Bahmer FA, Fritsch P, Kreusch J, Pehamberger H, Rohrer C, Dermatol 1995;131:436-40.
Schindera I, et al. Diagnostische Kriterien in der Auflichtsmik- 51. Argenziano G, Scalvenzi M, Staibano S, Brunetti B, Piccolo D,
roskopie. Konsensus-Treffen der Arbeitsgruppe Analytische Delfino M, et al. Dermatoscopic pitfalls in differentiating
Morphologie der Arbeitsgemeinschaft Dermatologische For- pigmented Spitz naevi from cutaneous melanomas. Br J
schung, 17 November 1989 in Hamburg. Hautarzt 1990;41:513-4. Dermatol 1999;141:788-93.
32. Argenziano G, Soyer HP, Chimenti S, Talamini R, Corona R, Sera 52. Argenziano G, Soyer HP, Ferrara G, Piccolo D, Hofmann-
F, et al. Dermoscopy of pigmented skin lesions: results of Wellenhof R, Peris K, et al. Superficial black network: an
a consensus meeting via the Internet. J Am Acad Dermatol additional dermoscopic clue for the diagnosis of pigmented
2003;48:679-93. spindle and/or epithelioid cell nevus. Dermatology 2001;
33. Anderson RR, Parrish JA. The optics of human skin. J Invest 203:333-5.
Dermatol 1981;77:13-9. 53. Steiner A, Pehamberger H, Binder M, Wolff K. Pigmented Spitz
34. Braun RP, Saurat JH, Krischer J. Diagnostic pearl: unmagnified nevi: improvement of the diagnostic accuracy by epilumines-
diascopy for large pigmented lesions reveals features similar cence microscopy. J Am Acad Dermatol 1992;27:697-701.
to those of epiluminescence microscopy. J Am Acad Dermatol 54. Massi D, De Giorgi V, Carli P, Santucci M. Diagnostic
1999;41:765-6. significance of the blue hue in dermoscopy of melanocytic
35. Bahmer FA, Rohrer C. Rapid and simple macrophotography of lesions: a dermoscopic-pathologic study. Am J Dermatopathol
the skin. Br J Dermatol 1986;114:135-6. 2001;23:463-9.
36. Argenziano G, Soyer HP, De Giorgi V, Piccolo D, Carli P, Delfino 55. Kreusch J, Rassner G. Auflichtmikroskopie pigmentierter
M, et al. Dermoscopy: a tutorial. 1st ed. Milano: EDRA; 2000. Hauttumoren. Stuttgart: Thieme; 1991.
37. Kenet RO, Kang S, Kenet BJ, Fitzpatrick TB, Sober AJ, Barnhill 56. Kreusch J, Rassner G, Trahn C, Pietsch-Breitfeld B, Henke D,
RL. Clinical diagnosis of pigmented lesions using digital Selbmann HK. Epiluminescent microscopy: a score of
120 Braun et al J AM ACAD DERMATOL
morphological features to identify malignant melanoma. 76. Kittler H, Pehamberger H, Wolff K, Binder M. Follow-up of
Pigment Cell Res 1992:295-8. melanocytic skin lesions with digital epiluminescence micros-
57. Kreusch J, Koch F. Auflichtmikroskopische Charakterisierung copy: patterns of modifications observed in early melanoma,
von Gefassmustern in Hauttumoren. Hautarzt 1996;47:264-72. atypical nevi, and common nevi. J Am Acad Dermatol
58. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Delfino M. 2000;43:467-76.
Epiluminescence microscopy: criteria of cutaneous melanoma 77. Menzies SW, Gutenev A, Avramidis M, Batrac A, McCarthy WH.
progression. J Am Acad Dermatol 1997;37:68-74. Short-term digital surface microscopic monitoring of atypical or
59. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Delfino M. changing melanocytic lesions. Arch Dermatol 2001;137:1583-9.
Clinical and dermatoscopic criteria for the preoperative 78. Stolz W, Schiffner R, Pillet L, Vogt T, Harms H, Schindewolf T,
evaluation of cutaneous melanoma thickness. J Am Acad et al. Improvement of monitoring of melanocytic skin lesions
Dermatol 1999;40:61-8. with the use of a computerized acquisition and surveillance
60. Argenyi ZB. Dermoscopy (epiluminescence microscopy) of unit with a skin surface microscopic television camera. J Am
pigmented skin lesions. Current status and evolving trends. Acad Dermatol 1996;35:202-7.
Dermatol Clin 1997;15:79-95. 79. Binder M, Steiner A, Schwarz M, Knollmayer S, Wolff K,
61. Carli P, De Giorgi V, Soyer HP, Stante M, Mannone F, Giannotti Pehamberger H. Application of an artificial neural network in
B. Dermatoscopy in the diagnosis of pigmented skin lesions: epiluminescence microscopy pattern analysis of pigmented
a new semiology for the dermatologist. J Eur Acad Dermatol skin lesions: a pilot study. Br J Dermatol 1994;130:460-5.
Venereol 2000;14:353-69. 80. Binder M, Kittler H, Seeber A, Steiner A, Pehamberger H, Wolff
62. Steiner A, Pehamberger H, Wolff K. In vivo epiluminescence K. Epiluminescence microscopy-based classification of pig-
microscopy of pigmented skin lesions. II. Diagnosis of small mented skin lesions using computerized image analysis and
pigmented skin lesions and early detection of malignant an artificial neural network. Melanoma Res 1998;8:261-6.
melanoma. J Am Acad Dermatol 1987;17:584-91. 81. Binder M, Kittler H, Dreiseitl S, Ganster H, Wolff K, Peham-
63. Braun RP, Rabinovitz H, Krischer J, Kreusch J, Oliviero M, Naldi berger H. Computer-aided epiluminescence microscopy of
L, et al. Dermoscopy of pigmented seborrheic keratosis. Arch pigmented skin lesions: the value of clinical data for the
Dermatol 2002;138:1556-60. classification process. Melanoma Res 2000;10:556-61.
64. Provost N, Kopf AW, Rabinovitz HS, Oliviero MC, Toussaint S, 82. Day GR, Barbour RH. Automated melanoma diagnosis: where
Kamino HH. Globulelike dermoscopic structures in pigmented are we at? Skin Res Technol 2000;6:1-5.
seborrheic keratosis. Arch Dermatol 1997;133:540-1. 83. Debeir O, Decaestecker C, Pasteels JL, Salmon I, Kiss R, Van
65. Braun RP, Rabinovitz H, Oliviero M, Kopf AW, Saurat JH, Ham P. Computer-assisted analysis of epiluminescence mi-
Thomas L. Dermatoscopy of pigmented lesions. Ann Dermatol croscopy images of pigmented skin lesions. Cytometry
Venereol 2002;129:187-202. 1999;37:255-66.
66. Schiffner R, Schiffner-Rohe J, Vogt T, Landthaler M, Wlotzke U, 84. Elbaum M, Kopf AW, Rabinovitz HS, Langley RG, Kamino H,
Cognetta AB, et al. Improvement of early recognition of Mihm MC Jr, et al. Automatic differentiation of melanoma
lentigo maligna using dermatoscopy. J Am Acad Dermatol from melanocytic nevi with multispectral digital dermoscopy:
2000;42:25-32. a feasibility study. J Am Acad Dermatol 2001;44:207-18.
67. Menzies SW, Westerhoff K, Rabinovitz H, Kopf AW, McCarthy 85. Fleming MG, Steger C, Zhang J, Gao J, Cognetta AB, Pollak I,
WH, Katz B. Surface microscopy of pigmented basal cell et al. Techniques for a structural analysis of dermatoscopic
carcinoma. Arch Dermatol 2000;136:1012-6. imagery. Comput Med Imaging Graph 1998;22:375-89.
68. Soyer HP, Argenziano G, Ruocco V, Chimenti S. Dermoscopy of 86. Gutenev A, Skladnev VN, Varvel D. Acquisition-time image
pigmented skin lesions (Part II). Eur J Dermatol 2001;11: quality control in digital dermatoscopy of skin lesions. Comput
483-98. Med Imaging Graph 2001;25:495-9.
69. Wang SQ, Katz B, Rabinovitz H, Kopf AW, Oliviero M. Lessons 87. Gutkowicz-Krusin D, Elbaum M, Jacobs A, Keem S, Kopf AW,
on dermoscopy #4. Poorly defined pigmented lesion. Di- Kamino H, et al. Precision of automatic measurements of
agnosis: pigmented BCC. Dermatol Surg 2000;26:605-6. pigmented skin lesion parameters with a MelaFind(TM) mul-
Stolz W, Riemann A, Cognetta AB, Pillet L, Abmayr W, Holzel D, tispectral digital dermoscope. Melanoma Res 2000;10:563-70.
et al. ABCD rule of Dermatoscopy: a new practical method for 88. Menzies SW. Automated epiluminescence microscopy: human
early recognition of malignant melanoma. Eur J Dermatol vs machine in the diagnosis of melanoma. Arch Dermatol
71. Braun RP, Rabinovitz H, Oliviero M, Kopf AW, Saurat JH. 89. Moncrieff M, Cotton S, Claridge E, Hall P. Spectrophotometric
Pattern analysis: a two step procedure for the dermoscopic intracutaneous analysis: a new technique for imaging pig-
diagnosis of melanoma. Clin Dermatol 2002;20:236-9. mented skin lesions. Br J Dermatol 2002;146:448-57.
72. Saida T, Oguchi S, Ishihara Y. In vivo observation of magnified 90. Murali A, Stoecker WV, Moss RH. Detection of solid pigment in
features of pigmented lesions on volar skin using video dermatoscopy images using texture analysis. Skin Res Technol
macroscope. Usefulness of epiluminescence techniques in 2000;6:193-8.
clinical diagnosis. Arch Dermatol 1995;131:298-304. 91. Rubegni P, Ferrari A, Cevenini G, Piccolo D, Burroni M, Perotti
73. Cognetta AB Jr, Stolz W, Katz B, Tullos J, Gossain S. Dermato- R, et al. Differentiation between pigmented Spitz naevus and
scopy of lentigo maligna. Dermatol Clin 2001;19:307-18. melanoma by digital dermoscopy and stepwise logistic
74. Kittler H, Seltenheim M, Pehamberger H, Wolff K, Binder M. discriminant analysis. Melanoma Res 2001;11:37-44.
Diagnostic informativeness of compressed digital epilumines- 92. Schmid P. Segmentation of digitized dermatoscopic images
cence microscopy images of pigmented skin lesions com- by two-dimensional color clustering. IEEE Trans Med Imaging
pared with photographs. Melanoma Res 1998;8:255-60. 1999;18:164-71.
75. Braun RP, Lemonnier E, Guillod J, Skaria A, Salomon D, Saurat 93. Smolle J. Computer recognition of skin structures using
JH. Two types of pattern modification detected on the follow- discriminant and cluster analysis. Skin Res Technol 2000;6:58-63.
up of benign melanocytic skin lesions by digitized epilumi- 94. Stoecker WV, Moss RH. Digital imaging in dermatology.
nescence microscopy. Melanoma Res 1998;8:431-7. Comput Med Imaging Graph 1992;16:145-50.
J AM ACAD DERMATOL Braun et al 121
VOLUME 52, NUMBER 1
95. Braun RP, Meier M, Pelloni F, Ramelet AA, Schilling M, 2. Menzies SW, Crotty KA, Ingvar C, McCarthy WH. An atlas of
Tapernoux B, et al. Teledermatoscopy in Switzerland: a pre- surface microscopy of pigmented lesions. Sydney: McGraw-Hill
liminary evaluation. J Am Acad Dermatol 2000;42:770-5. Company; 1996.
96. Piccolo D, Smolle J, Argenziano G, Wolf IH, Braun R, Cerroni L, 3. Stolz W, Braun-Falco O, Bilek P, Landthaler M, Burgdorf WHC,
et al. Teledermoscopy—results of a multicentre study on 43 Cognetta AB. Color atlas of dermatoscopy. 2nd ed. Berlin:
pigmented skin lesions. J Telemed Telecare 2000;6:132-7.
Blackwell Wessenschafts-Verlag; 2002.
97. Piccolo D, Smolle J, Wolf IH, Peris K, Hofmann-Wellenhof R,
4. Soyer HP, Argenziano G, Chimenti S, Rabinovitz HS, Stolz W,
Dell’Eva G, et al. Face-to-face diagnosis vs telediagnosis of
pigmented skin tumors: a teledermoscopic study. Arch Der- Kopf AW, et al. Dermoscopy of pigmented lesions. Milan: EDRA;
matol 1999;135:1467-71. 2001.
98. Provost N, Kopf AW, Rabinovitz HS, Stolz W, DeDavid M, Wasti 5. Rabinovitz HS, Cognetta AB. Dermatologic clinics. Philadelphia
Q, et al. Comparison of conventional photographs and tele- (PA): WB Saunders; 2001.
phonically transmitted compressed digitized images of mela- 6. Johr R, Soyer HP, Argenziano G, Hofmann-Wellenhof R,
nomas and dysplastic nevi. Dermatology 1998;196:299-304. Scalvenzi M. Dermoscopy: The essentials. London: Mosby; 2004.
8. Marghoob AA, Braun RP, Kopf AW. Atlas of dermoscopy.
ADDITIONAL READING London: Taylor & Francis; 2005.
1. Argenziano G, Soyer HP, De Giorgi V, Piccolo D, Carli P, et al. 9. Malvehy J, Puig S. Principles of dermoscopy. Barcelona: CEGE
Dermoscopy: A tutorial. 1st ed. Milan: EDRA; 2000. Editors; 2002.