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Dermoscopy of pigmented skin lesions

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Dermoscopy of pigmented skin lesions Document Transcript

  • 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.) 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: braun@melanoma.ch. 0190-9622/$30.00 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. 109
  • 2. 110 Braun et al J AM ACAD DERMATOL JANUARY 2005 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, 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 border 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
  • 3. 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.41-43 679-93.32 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
  • 4. 112 Braun et al J AM ACAD DERMATOL JANUARY 2005 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.
  • 5. 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.
  • 6. 114 Braun et al J AM ACAD DERMATOL JANUARY 2005 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 lesion Homogeneous colors Homogeneous colors Symmetric papular ‘‘Pseudonetwork’’ No pseudonetwork appearance All criteria for ‘‘Comma’’-shaped melanocytic lesion blood vessels possible Color heterogeneity possible y 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.
  • 7. 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 structures) interruptions 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 margin comedo-like openings (plugs) Structureless areas Gray-white veil Rough surface ‘‘Dirty’’ gray-brown to gray-black colors Gray-blue or red-rose Absence of primary Abrupt border cut-off veils criteria for malignant melanoma Red Opaque gray-brown colors Pseudopods/radial streaming Point and hairpin vessels 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 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).
  • 8. 116 Braun et al J AM ACAD DERMATOL JANUARY 2005 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 Broadened network 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
  • 9. J AM ACAD DERMATOL Braun et al 117 VOLUME 52, NUMBER 1 Table VI. Pattern of benign and malignant lesions Benign Malignant 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 cobblestone pattern 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 symmetrically 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
  • 10. 118 Braun et al J AM ACAD DERMATOL JANUARY 2005 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. these areas.32,36,71 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. 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