Cabo H. Color Atlas of Dermoscopy 2018

Color Atlas of
Dermoscopy
Color Atlas of
Dermoscopy
Horacio Antonio Cabo MD PhD

Head Professor of Dermatology
Universidad de Buenos Aires (UBA)
Buenos Aires, Argentina
Specialist in Dermatology
Head of Dermatology
Institute of Medical Research
Ex-President
The Argentine Society of Dermatology
Member
Executive Committee of Ibero-Latin Americano College
of Dermatology (CILAD) and
The Board of the International Dermoscopy Society (IDS)
Graz, Austria
Foreword
Fernando Stengel
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Color Atlas of Dermoscopy

First Edition: Digital Version 2018
ISBN: 978-93-86056-30-6
Dedicated to
My wife, sons and daughters, grandchildren and my patients
Contributors
Giuseppe Albertini MD Institute of Medical Research Harald Kittler MD
Dermatologist Universidad de Buenos Aires (UBA) AO Professor
Italy Ex-President Department of Dermatology
The Argentine Society of Dermatology Medical University of Vienna
Zoe Apalla MD Member Vienna, Austria
Dermatologist Executive Committee of
Greece Ibero-Latin Americano College Aimilios Lallas MD MSc PhD
of Dermatology (CILAD) and Dermatologist-Venereologist
Giuseppe Argenziano MD PhD The Board of the International First Department
Dermoscopy Society (IDS) of Dermatology
Professor and Head
Graz, Austria
Dermatology Unit Aristotle University
University of Campania Thessaloniki, Greece
Stefano Caccavale MD
Naples, Italy
Dermatologist Caterina Longo MD
Italy
Renato Marchiori Bakos MD PhD Professor of Dermatology
Professor of Dermatology Dermatology Unit
Nathalie De Carvalho MD
Universidade Federal do Rio University of Modena and Reggio
Dermatologist Emilia, Italy
Grande do Sul
Brazil
Porto Alegre, Brazil
Amalia Lupoli MD
Teresa Deinlein MD
Elisa Benatti MD Dermatologist
Dermatologist
Dermatologist Italy
University of Graz
Italy
Graz, Austria
Marco Manfredini MD
Stefania Borsari MD Dermatologist
Paula Friedman MD
Dermatologist Italy
Dermatologist
Italy Department of Dermatology
Instituto de Investigaciones Médicas Carolina Marcucci MD
Gabriella Brancaccio MD ‘A Lanari’ Dermatologist
Dermatologist University of Buenos Aires Hospital Alvarez
Italy Buenos Aires, Argentina Buenos Aires, Argentina
Horacio A Cabo MD PhD Alessio Gambardella MD Elvira Moscarella MD

Head Professor of Dermatology Dermatologist Dermatologist
Universidad de Buenos Aires (UBA) Italy Dermatology and Skin
Buenos Aires, Argentina Cancer Unit
Specialist in Dermatology Stefano Gardini MD Arcispedale S Maria Nuova
Universidad de Buenos Aires (UBA) Dermatologist IRCCS Reggio
Head of Dermatology Italy Emilia, Modena, Italy
viii Color Atlas of Dermoscopy
Giovanni Pellacani MD Lidia Rudnicka MD PhD Santa Fe, Argentina

Full Professor and Chairman Professor
Department of Dermatology Department of Dermatology Philipp Tschandl MD PhD
University of Modena and Reggio President Dermatologist
Emilia, Modena, Italy Polish Dermatological Society Department of Dermatology
Chairman Medical University of Vienna
Department of Dermatology Vienna, Austria
María Rosario Peralta MD Medical University of Warsaw
Dermatologist Warsaw, Poland Iris Zalaudek MD PhD
University of Buenos Aires
Honorary Assistant Dermatologist
Emilia Noemi Cohen Sabban MD Associate Professor
Medical Research Institute
Dermatologist Division of Dermatology
University of
Deputy Chief of the Instituto de Medical University of Graz
Buenos Aires
Investigaciones Graz, Austria
Médicas A Lanari President
University of Buenos Aires International Dermoscopy Society
Simonetta Piana MD Buenos Aires, Argentina Graz, Austria
Dermatologist Assistant Professor
Italy Department of Dermatology
Cliff Rosendahl MBBS PhD Buenos Aires, Argentina
Associate Professor
University of Queensland Gabriel Salerni MD PhD
Australia Dermatologist, Doctor in Medicine
Distinguished Visiting Professor Universidad Nacional de Rosario
Tehran University of Medical and Hospital Provincial del
Sciences Centenario de Rosario
Tehran, Iran
Foreword
If you believe that augmenting your diagnostic skills with available, office-based and cheap hand-held intruments is
your duty as a dermatologist, this book will prove helpful to you.
Drawn from personal experience and in association with a group of world-recognized experts, Professor Cabo covers
the growing field of Dermoscopy, including melanocytic and nonmelanocytic lesions, benign and malignant total body
follow-up photography, entomodermatoscopy, inflammatoscopy, tricoscopy, capillaroscopy and in vivo reflectance
confocal microscopy.
The information in this state-of-the-art volume is presented in a simple manner, with the aid of clear diagrams, that
emphasize the things one should look out for. Data are highlighted with the use of tables that single out the characteristic
signs of each individual entity.
The authors present a user-friendly book, a practically rapid consultation reference in the office.
As the use of the dermatoscope expands, so have its applications widened, well beyond the original differential
diagnosis of melanocytic lesions. The recognition of vascular patterns associated with nonpigmented (amelanotic)
melanomas, the importance of diagnostic algorithms, the chapters on Revised Pattern Analysis and Chaos and Clues,
all emphasize the fact that dermoscopy is a rapidly evolving diagnostic technique. Thus, to achieve high specificity and
sensitivity, the method requires knowledge and hands-on expertise.
It is no surprise that colleagues with this wonderful hand-held device—a dermatoscope—would begin to visualize
the normal and disease-related fauna on/in the skin superficial layers; that they would look at hairs, nailfolds and
nailbed and ‘dig into’ inflammatory skin conditions. The results of their efforts are well represented in the corresponding
chapters!
The main author of this book hopes that his readers may improve their dermoscopic skills for the benefit of their
patients. Color Atlas of Dermoscopy is a step in the right direction.
Fernando Stengel MD
Ex-Assistant Professor
Skin & Cancer Unit
New York University
New York City, New York, USA
Ex-Chief
Department of Dermatology
Clinical Hospital
Ex-Chief
Centro de Educación Médica e Investigaciones
Clínicas (CEMIC)
Preface
Many years have passed since I began to use the dermatoscope with nonpolarized light.
For over twenty years, I have attended courses, I have read many journals and books, I have published articles, my
own books, CD-ROMs, I have taught numerous courses, and presented hundreds of cases.
Today, I finish a much-cherished project, my first book in English.
Here I share all the experiences amassed in these years. I hope, dear reader, that you will find it useful to improve
your dermoscopic learning for the benefit of your patients.
Horacio Antonio Cabo
Acknowledgments
To Estela Riviere for helping me in this project.
To all the contributors.
I thank Mr Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Ms Chetna Malhotra Vohra
(Associate Director–Content Strategy), Ms Angima Shree (Senior Development Editor) and the production team
of Jaypee Brothers Medical Publishers, New Delhi, India for giving us a go-ahead at the very beginning and helping us
in every way possible to bring out this book.
Contents
1. Why Use the Dermatoscope 1
Horacio A Cabo
2. Structures, Patterns, Criteria and Colors 13
Horacio A Cabo
3. Vascular Patterns 21
Emilia Noemi Cohen Sabban, Horacio A Cabo
4. Dermoscopy: A Two-Step Procedure 31
Horacio A Cabo
5. Nonmelanocytic Lesions 39
Horacio A Cabo
5.1 Seborrheic Keratosis 41
Horacio A Cabo
5.2 Solar Lentigo 49
Horacio A Cabo
5.3 Basal Cell Carcinoma 54
Horacio A Cabo
5.4 Angiomas and Angiokeratomas 72
Horacio A Cabo
5.5 Dermatofibroma 77
Horacio A Cabo
5.6 Actinic Keratoses 83
Rosario Peralta, Horacio A Cabo
5.7 Keratoacanthoma, Bowen’s Disease and Squamous Cell Carcinoma 88
5.8 Other Nonmelanocytic Lesions 96
5.8.1 Eccrine Poroma 96
Carolina Marcucci, Horacio A Cabo
5.8.2 Clear Cell Acanthoma 99
5.8.3 Cylindroma 100
5.8.4 Trichoepithelioma 101
5.8.5 Verrucae Vulgaris 102
Paula Friedman, Horacio A Cabo
5.8.6 Molluscum Contagiosum 103
5.8.7 Sebaceous Hyperplasia 104
xvi Color Atlas of Dermoscopy
5.8.8 Porokeratosis 106

5.8.9 Pyogenic Granuloma 107
Horacio A Cabo
5.8.10 Lichen Planus 108
5.8.11 Bowenoid Papulosis 109
6. Melanocytic Lesions 111
Horacio A Cabo
6.1 Criteria of Melanocytic Lesions 113
Horacio A Cabo
6.2 Nevogénesis 120
Aimilios Lallas, Zoe Apalla, Elvira Moscarella, Caterina Longo, Teresa Deinlein, Iris Zalaudek
6.3 Congenital Melanocytic Nevi 124
Horacio A Cabo
6.4 Acquired Melanocytic Nevi 135
Horacio A Cabo
6.5 Atypical Nevus (Dysplastic) 140
Horacio A Cabo
6.6 Spitz Nevus 145
Stefano Caccavale, Alessio Gambardella, Amalia Lupoli, Gabriella Brancaccio, Giuseppe Argenziano
6.7 Blue Nevus and Combined Nevus 152
Horacio A Cabo
6.8 Recurrent Nevus 158
Horacio A Cabo
6.9 Melanoma 162
Horacio A Cabo
6.9.1 Superficial Spreading Melanoma 162
Horacio A Cabo
6.9.2 Nodular Melanoma 173
Horacio A Cabo
6.9.3 Lentigo Maligna Melanoma 177
Horacio A Cabo
6.9.4 Acral Melanoma 184
Horacio A Cabo
6.9.5 Amelanotic Melanoma 189
Horacio A Cabo
6.9.6 Dermoscopy Approach in Patients with Multiple Nevi 196
Horacio A Cabo
7. Melanoma Simulators 205
Horacio A Cabo
8. Combined Lesions 215
Horacio A Cabo
9. Special Locations 221
Horacio A Cabo
Contents xvii
9.1 Face 223

Horacio A Cabo
9.2 Palms and Soles 227
Horacio A Cabo
9.3 Mucosa 237
Horacio A Cabo
9.4 Nails 242
Horacio A Cabo
10. Diagnostic Algorithms 247
Horacio A Cabo
11. Total-Body Photography and Sequential Digital Dermoscopy Images 255
Gabriel Salerni
12. Revised Pattern Analysis 265
Cliff Rosendahl, Harald Kittler
13. Entomodermoscopy 285
Renato Marchiori Bakos
14. Inflammatoscopy 293
15. Trichoscopy 299
Lidia Rudnicka
16. Capillaroscopy 307
Emilia Noemi Cohen Sabban
17. Reflectance Confocal Microscopy 321
Giovanni Pellacani, Caterina Longo, Elvira Moscarella
17.1 The Utility of Confocal Microscopy in the Diagnosis of Superficial Spreading Melanoma 323
Giovanni Pellacani, Nathalie De Carvalho
17.2 The Utility of Confocal Microscopy in the Diagnosis of Basal Cell Carcinoma 328
Caterina Longo, Simonetta Piana, Elisa Benatti, Stefania Borsari, Giuseppe Albertini,
Aimilios Lallas, Elvira Moscarella
17.3 The Utility of Confocal Microscopy in the Diagnosis of Squamous Cell Carcinoma 333
Elvira Moscarella, Simonetta Piana, Marco Manfredini, Stefano Gardini,
Giuseppe Albertini, Aimilios Lallas, Caterina Longo
18. Dermatoscopy—Chaos and Clues 339
Philipp Tschandl, Cliff Rosendahl
Index 345
WHY USE THE
DERMATOSCOPE 1
Horacio A Cabo
“Dermoscopy is a noninvasive technique that improves the
clinical diagnosis of pigmented and nonpigmented lesions.
This technique allows us to differentiate melanoma from other melanocytic
and nonmelanocytic lesions according to new morphological criteria.
Under clinical examination, many nevi and melanomas have clinical characteristics
which sometimes make them look very similar. This happens with some melanocytic lesions.
With the dermatoscope, benign or malignant patterns may be identified and in this manner,
the diagnostic accuracy can be improved as compared with the clinical examination.”
Why Use the Dermatoscope 3
Dermoscopy is a noninvasive technique that improves •• It is the merges of clinical dermatology (macroscopy)
the clinical diagnosis of pigmented and nonpigmented and dermatopathology (microscopy) (Figs. 1.9 to 1.14).
lesions. •• Dermoscopy improves clinical diagnosis of pigmented
It has been used for over 20 years and in this first skin lesions by 10–30% (Figs. 1.15 to 1.20 and Table 1.1).
chapter we will see briefly why we should incorporate it •• Dermoscopy improves the diagnosis of nail lesions
to our patients’ routinely examination. (Figs. 1.21 to 1.25).
•• This technique allows us to differentiate melanoma •• Dermoscopy improves the diagnosis of palm and sole
from other melanocytic and nonmelanocytic lesions lesions (Figs. 1.27 and 1.28).
according to new morphological criteria (Figs. 1.1 •• Dermoscopy reduces the number of unnecessary
to 1.8). cutaneous biopsies (40%).
Fig. 1.1: Clinical image of a pigmented lesion where it is difficult to Fig. 1.2: Dermoscopic image of the lesion in Figure 1.1, where the
distinguish whether it is a melanocytic or a nonmelanocytic lesion. criteria for seborrheic keratosis are clearly observable. (A) Multiple
pseudocysts. (B) Pseudo follicular openings.
Fig. 1.3: Clinical image of a pigmented lesion where it is difficult to Fig. 1.4: Dermoscopic image of the lesion in Figure 1.3, where the
distinguish whether it is a melanocytic or a nonmelanocytic lesion. criteria for seborrheic keratosis are clearly observable. (A) Multiple
pseudocysts. (B) Pseudo follicular openings.
4 Color Atlas of Dermoscopy
Fig. 1.5: Clinical image of a pigmented lesion where it is difficult to Fig. 1.6: Multiple hairpin vessels in the periphery (red circle).
distinguish whether it is a melanocytic or a nonmelanocytic lesion.
Fig. 1.7: Clinical image of a pigmented lesion where it is difficult to Fig. 1.8: Dermoscopic image of a melanoma. (A) Atypical pigment
distinguish whether it is a melanocytic or a nonmelanocytic lesion. network. (B) Blue-white veil. (C) Negative pigment network.
Fig. 1.9: Pigment network in a nevus with reticular pattern. Fig. 1.10: Histological correlation of the pigment network.
Fig. 1.11: Brown globules in a nevus with globular pattern. Fig. 1.12: Histological correlation of the globules.
Fig. 1.13: Streaks or projections. Fig. 1.14: Histological correlation of the streaks or projections.
Fig. 1.15: Clinical image of a 12-year-old patient with a symmetrical Fig. 1.16: Dermoscopic image where it is possible to observe the
black lesion, where it is difficult to perform a clinical diagnosis. starburst pattern (peripheral projections over the whole lesion) typical
of the Spitz nevus.
Fig. 1.17: Clinical image of a symmetrical raised lesion with multiple Fig. 1.18: Dermoscopic image of combined lesion with a diagnosis
colors and difficult clinical diagnosis. of combined nevus. The central area presents a homogeneous blue
coloration (deep component) corresponding to a blue nevus, (A) and
the periphery (superficial component) presents a pigment network
corresponding to a compound nevus (B).
Fig. 1.19: Clinical image of a blue-black pigmented lesion with fast Fig. 1.20: Dermoscopic image of a hemangioma, with multiple red
onset and difficult clinical diagnosis. blue areas (lacunae).
Table 1.1: Diagnostic accuracy in pigmented lesions. •• The diagnosis of melanoma with few dermoscopic
characteristics has improved with the short-term and
Without dermatoscope (%) 65–85
the long-term follow-up (Figs. 1.29 to 1.32).
With dermatoscope (%) 85–95
•• Dermoscopy with polarized light with or without con-
Dermoscopy improves clinical diagnosis (%) 10–30 tact has improved the diagnosis of nonpigmented
lesions (Figs. 1.33 to 1.38).
•• Dermoscopy improves the diagnosis of pigmented
–– Dermoscopy decreases the benign/malignant lesions of the mucosae (Figs. 1.39 to 1. 42).
ratio of excised lesions: •• Dermoscopy has been shown to improve the treat-
▪▪ Predermoscopy 18:1 (we need to remove 18 ment of pigmented lesions in children and adoles-
benign lesions to find a melanoma) cents and reduce the number of unnecessary excisions
▪▪ Dermoscopy 4:1 (Fig. 1.43).
Fig. 1.21: Subungual hematoma. Fig. 1.22: Subungual hematoma.
Fig. 1.23: Subungual hematoma. Fig. 1.24: Nevus: Brown background pigmentation with regular longi
tudinal bands.
Fig. 1.25: Melanoma: Brown background pigmentation with irregular Fig. 1.26: Acral nevi with parallel furrow pattern.
longitudinal bands (arrows).
Fig. 1.27: Melanoma with parallel ridge pattern. Fig. 1.28: Diagram of skin histology in acral areas.
Fig. 1.29: Pigmented lesion in the neckline. Fig. 1.30: Melanoma in situ in thorax. Dermoscopy of lesion in
Figure 1.29 with patent changes in the digital follow-up.
Fig. 1.31: Pigmented lesion in neckline showing clinical changes in Fig. 1.32: Spreading superficial melanoma B 0.37. Dermoscopy of the
4 months. lesion in Figure 1.31, showing obvious changes in the digital follow-up.
Fig. 1.33: Pink lesion in anterior foot of difficult clinical diagnosis. Fig. 1.34: Dermoscopy of the lesion in Figure 1.33, where it is possible
to observe glomerular vessels with focal distribution. Diagnosis:
squamous cell carcinoma.
Fig. 1.35: Close-up view of Figure 1.34 (red circle shows glomerular Fig. 1.36: Pink lesion in the right arm, difficult to diagnose clinically.
vessels with focal distribution ).
Fig. 1.37: Dermoscopy of lesion in Figure 1.36, where it is possible Fig. 1.38: Close-up view of Figure 1.37.
to observe irregular lineal and dot-like vessels. Diagnosis: Hypome
lanotic melanoma.
Fig. 1.39: Pigmented lesion on the lower lip, difficult to diagnose. Fig. 1.40: Dermoscopy of lesion in Figure 1.39. Labial melanotic
macula. Fish-scale pattern (arrow).
Fig. 1.41: Pigmented lesion on genitalia, difficult to diagnose (arrow). Fig. 1.42: Dermoscopy of the lesion in Figure 1.40. Genital melanotic
macula. Fingerprint pattern.
Table 1.2: Comparative dermoscopic approach.

Predominant nevus pattern (signature nevus)
The different lesion
Clinically and dermoscopically (ugly duckling sign)
Dermoscopically (Little Red Riding Hood sign)
•• Dermoscopy has been shown to improve the diagnosis

of patients with multiple nevi using the comparative
dermoscopic approach (Table 1.2).
–– Dermoscopy improves the diagnostic accuracy
(specificity and sensitivity) of pigmented lesions
Fig. 1.43: A 12-year-old boy with multiple excisions of typical nevi (Figs. 1.44 and 1.45). Sensitivity is the capacity to
(1–6). Example of what not to do. detect melanomas.
Fig. 1.44: Sensitivity: Capacity to detect melanoma. The lesion in the red Fig. 1.45: Specificity: Capacity to detect nonmelanoma. In these
circle is quickly identified as atypical and different from the other nevi. examples, it is very difficult to distinguish atypical nevi from melanoma.
–– Specificity is the capacity to detect nonmelanomas. Carli P, de Giorgi V, Chiarugi A, et al. Addition of dermoscopy to
▪▪ Sensitivity = TP/(TP + FN) conventional naked-eye examination in melanoma screen-
ing: a randomized study. J Am Acad Dermatol. 2004;50:683-9.
▪▪ Specificity = TN/(TN + FP) Carli P, de Giorgi V, Crocetti E, et al. Improvement of malignant/
▪▪ TP: true-positive results benign ratio in excised melanocytic lesions in the “dermos-
▪▪ TN: true-negative results copy era”: a retrospective study 1997–2001. Br J Dermatol.
▪▪ FN: false-negative results 2004;150(4):687-92.
Carli P, de Giorgi V, Soyer HP, et al. Dermoscopy in the diagnosis
▪▪ FP: false-positive results—Lesions which were of pigmented skin lesions: a new semiology for the dermatol-
clinically diagnosed as melanoma and whose ogist. J Eur Acad Dermatol Venereol. 2000;14(5):353-69.
histopathological study proved them to be nevi. Haenssle HA, Krueger U, Vente C, et al. Results from an obser-
Under clinical examination many nevi and melano- vational trial: digital epiluminescence microscopy follow-up
of atypical nevi increases the sensitivity and the chance of
mas have clinical characteristics which sometimes make success of conventional dermoscopy in detecting melanoma.
them look very similar. This happens with some melano- J Invest Dermatol. 2006;126:980-5.
cytic lesions. Johr RH, Izakovic J. Dermoscopy/ELM for the evaluation of
With the dermatoscope, benign or malignant patterns nail-apparatus pigmentation. Dermatol Surg. 2001;27:315-22.
Kittler H, PehambeKittler H, Pehamberger H, et al. Diagnostic
may be identified and in this manner the diagnostic accu- accuracy of dermoscopy. Lancet Oncol. 2002;3:159-65.
racy can be improved as compared with the clinical exami Menzies S, Zalaudek I. Why perform dermoscopy? The evidence
nation. for its role in the routine management of pigmented skin
lesions. Arch Dermatol. 2006;142:1211-2.
Menzies SW. Cutaneous melanoma: making a clinical diagnosis,
SUGGESTED READING present and future. Dermatol Ther. 2006;19:32-9.
Menzies SW, Gutenev A, Avramidis M, et al. Short-term digi-
Altamura D, Altobelli E, Micantonio T, et al. Dermoscopic pat-
tal surface microscopic monitoring of atypical or changing
terns of acral melanocytic nevi and melanomas in a white
melanocytic lesions. Arch Dermatol. 2001;137:1583-9.
population in central Italy. Arch Dermatol. 2006;142:1123.
Pehamberger H, Binder M, Steiner A, et al. In vivo epilumines-
Bauer J, Metzler G, Rassner G, et al. Dermoscopy turns histopa- cence microscopy: improvement early diagnosis of mela-
thologist’s attention to the suspicious area in melanocytic noma. J Invest Dermatol. 1993;100(3):356-62.
lesions. Arch Dermatol. 2001;137:1338-40. Skvara H, Teban L, Fiebiger M, et al. Limitations of dermoscopy in
Braun RP, Kaya G, Masouye I, et al. Histopathologic correlation the recognition of melanoma. Arch Dermatol. 2005;141:155-60.
in dermoscopy: a micropunch technique. Arch Dermatol. Tosti A, Argenziano G. Dermoscopy allows better management of
2003;139:349-51. nail pigmentation. Arch Dermatol. 2002;138:1369-70.
STRUCTURES, PATTERNS,
CRITERIA AND COLORS 2
Horacio A Cabo
“” The multiple repetitions of a structure form a pattern.
When the structures are associated with certain pigmented lesions and
their observation implies defining a given lesion, they are called criteria.
In this manner, there are criteria for melanocytic and nonmelanocytic lesions
and such criteria will be explored in different chapters of this book.
Besides the structures, different colors can be observed which help,
elaborate the dermoscopic diagnosis.
It is necessary to consider type, number, and color distribution.””
Structures, Patterns, Criteria and Colors 15
By modifying the optic characteristics of the skin, the der- In Chapter 12, we will see that there are five basic ele-
matoscope makes it possible to see different shapes or ments (lines, dots, areas, pseudopods, and circles) with
structures that cannot be discerned with the naked eye which all dermoscopic structures can be described with-
(Fig. 2.1). out using the metaphoric method (Fig. 2.4).
These shapes or structures are given a name to iden- Just as under clinical examination we can recognize
tify them. At the beginning, a metaphoric language was a papule or blister, under dermoscopic examination it is
used; for example, “spoke-wheel areas” or “starburst”;
possible to recognize, for instance, pigment network or
but this made learning difficult for beginners. For some
brown globules (Figs. 2.5 and 2.6).
years now, this metaphoric language has been combined
Identifying all these dermoscopic structures is as nec-
with or even replaced by a new morphologic one in which,
as we will see hereunder, new terms are applied; so, for essary as recognizing basic dermatologic lesions. These
example, what used to be called brown globules and blue- structures are like the letters of the alphabets, and recog-
gray ovoid nests are now given the morphologic names nizing them makes it possible “to read” the different pig-
of Brown Areas and Blue-Gray Areas (Figs. 2.2 and 2.3). mented lesions with the dermoscope.
Fig. 2.1: Light reflection scheme. Fig. 2.2: Brown globules or brown areas (compound nevi).
Fig. 2.3: Gray-blue ovoid nests or gray-blue areas (basal cell carcinoma). Fig. 2.4: Basic elements.
The multiple repetitions of a structure form a pattern. Besides the structures, different colors can be observed
When the structures are associated with certain pig- which help elaborate the dermoscopic diagnosis.
mented lesions and their observation implies defining a Color is extremely important; just imagine having to
given lesion, they are called criteria (Fig. 2.7). differentiate brown globules from blue or red areas if we
In this manner, there are criteria for melanocytic and saw everything in black and white (Figs. 2.17 and 2.18).
nonmelanocytic lesions, as can be observed in Tables 2.1 It is necessary to consider type, number, and color dis-
to 2.4, and such criteria will be explored in different chap- tribution. Skin color is determined mainly by hemoglobin
ters of this book (Figs. 2.8 to 2.16). and melanin.
Fig. 2.5: Pigment network. Fig. 2.6: Brown globules.
Fig. 2.7: Structure: globules; pattern: globular; “brown globules are a criterion
for melanocytic lesions.
Table 2.1: Dermoscopic criteria for melanocytic lesions (Figs. 2.8 to Table 2.2: Dermoscopic criteria for seborrheic keratosis (Figs. 2.12
2.11). to 2.14).
Pigment Aggregated Streaks or Homogeneous Parallel Classic seborrheic keratosis Flat seborrheic keratosis (Lentigo solaris)
network globules projections blue pattern Milia-like cysts Fingerprint-like structures
pigmentation
Comedo-like openings Moth-eaten border
(irregular ridges) Jelly sign
Fissures and ridges
(similar to brain surface)
Vascular pattern
Table 2.3: Dermoscopic criteria for basal cell carcinoma (Fig. 2.15). Table 2.4: Dermoscopic criteria for angioma (Fig. 2.16).
Vascular pattern Blue-gray pigmentation Ulceration Blue-red lacunes: round areas of blue or red color
Thick vessels with multiple Leaf-like or digit-like struc
branching or arborizing tures
vessels Big ovoid nests or structures
Multiple globules
Radiated areas
Fig. 2.8: Compound nevi. Pigment network and aggregated brown Fig. 2.9: Melanoma. Projections or streaks.
globules.
Fig. 2.10: Blue nevus. Homogeneous blue pigmentation. Fig. 2.11: Acral nevus. Furrow parallel pattern.
The different colors that can be observed are white, Brown color is generally related to melanin. Depend-
red, black, blue, gray, yellow, light brown, and dark brown ing on where it is located, melanic pigment will be visuali
and their combinations or variants. Colors red, pink, or zed in different colors, due to the Tyndall effect (Fig. 2.22).
blue-red, and occasionally light brown, are related to the When it is located in the stratum corneum or epider-
vessels, with the presence of hemoglobin and the degree mis, it looks black; if it lies in the dermoepidermal junc-
of oxidation (Fig. 2.19). tion and in the papillary dermis, it looks dark brown or
White color represents lack of pigment, atrophy, or fibro- light brown; and if it is located in the dermis, it looks blue
sis (Fig. 2.20), while yellow corresponds to keratin (Fig. 2.21). (Fig. 2.23).
Fig. 2.12: Seborrheic keratosis. Multiple pseudocysts and pseudo- Fig. 2.13: Solar lentigo. Fingerprint-like structures and concave border.
openings.
Fig. 2.14: Seborrheic keratosis. Brain-like pattern. Fig. 2.15: Basal cell carcinoma. Arborizing vessels and blue-gray pig-
mentation.
Fig. 2.16: Hemangioma. Red-blue areas. Fig. 2.17: Lesion in black and white. Diagnosis: Nevus.
Fig. 2.18: Lesion in black and white. Diagnosis: angioma. Fig. 2.19: Examples of different colors.
Fig. 2.20: Melanoma. White color. Fig. 2.21: Seborrheic keratosis. Yellow color.
Fig. 2.22: Different colors seen with dermoscopy depending on Fig. 2.23: Example of different colors due to melanic pigment.
localization (Tyndall effect).
SUGGESTED READING Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-

ciones Gráficas; 2009.
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
of Dermoscopy. Milán: EDRA Medical Publishing & New Taylor & Francis; 2005.
Media; 2000. Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros-
Cabo H. Dermatoscopia. Buenos Aires: Weber Ferro; 2000. copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Company; 1996.
Ediciones Journal; 2012. Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
American Academy of Dermatology; 1999.
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment
Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig-
Guide, 2nd edition. New York: McGraw-Hill Education;
mented Skin Lesions. An Atlas Based on the Consensus Net
2015. Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials New Media; 2001.
(MOABT). New York: Elsevier Ltd; 2004. Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos-
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat- copy. USA: Blackwell Science; 1994.
tern Analysis. 2011 Facultas Verlags- und Buchhandels AG Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of non-
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at pigmented skin tumors. Boca Raton, FL: CRC Press; 2016.
VASCULAR PATTERNS 3
Emilia Noemi Cohen Sabban, Horacio A Cabo
”In order to follow a diagnostic algorithm for dermoscopic

lesions with blood vessels, it is recommended to
perform the following steps:
• Observe the morphology of the blood vessels.
• Observe the arrangement of the blood vessels in the lesion.
• Differentiate a monomorphic pattern from a polymorphic one“
Vascular Patterns 23
Initially, dermoscopy was performed using dermato Dermoscopy of the vascular pattern of a lesion may be
scopes with nonpolarized light, inserting an interphase liq the only tool for the diagnosis of nonpigmented cutaneous
uid (oil or alcohol) between the skin and the glass plate of tumors. The prevailing vascular pattern will also depend
the dermatoscope and exerting pressure to visualize lesi on tumor volume and progression. Therefore, a thin, more
ons (Fig. 3.1). This obviously produced a whitening effect recent tumor will generally have a vascular pattern differ
and prevented the observation of vessels (Fig. 3.2). With ent from that of a thicker, more advanced one (Table 3.1).
the use of ultrasound or high-thickness ecograph gels and Nevertheless, there are many benign and malignant
without applying so much pressure, vessels can be clearly lesions that can present similar vascular patterns. The
observed, although they are difficult to register. With the color of the different vascular structures is pink, red, or
coming of dermatoscopes with polarized light with or sometimes bluish. The distribution and morphology of the
without contact, the different types of vessels and pink vessels are very helpful for the clinical dermoscopic diag
areas are easily observed (Figs. 3.3 and 3.4). nosis.
Fig. 3.1: Nonpolarized light dermatoscope. Fig. 3.2: Image of a hypomelanotic melanoma captured with a
nonpolarized light dermatoscope.
Fig. 3.4: Hypomelanotic melanoma image captured with a polarized

Fig. 3.3: Polarized light dermatoscope. light dermatoscope.
In order to follow a diagnostic algorithm for dermo •• Differentiate a monomorphic pattern from a polymor
scopic lesions with blood vessels, it is recommended to phic one (Figs. 3.5 to 3.7).
perform the following steps:
•• Observe the morphology of the blood vessels.
•• Observe the arrangement of the blood vessels in the
MORPHOLOGY
lesion. Depending on their position in the skin, vessels can be
seen as round or linear.
Table 3.1: Dermoscopy.
Round or Dotted Vessels
• Dermoscopy with nonpolarized light
• Dermoscopy with polarized light
•• They can be small like dots, or larger, in which case
they are called clods (areas or globules) (Figs. 3.8 and 3.9).
–– With contact
•• Lagoons or lacunae: Large red areas, usually clustered,
–– Without contact
resembling lakes (Fig. 3.10).
Fig. 3.5: Diverse vessel morphology. Fig. 3.6: Diverse vessel distribution.
Fig. 3.7: Monomorphic and polymorphic patterns. Fig. 3.8: Dotted vessels—psoriasis.
Fig. 3.9: Clod vessels (areas or globules) squamous cell carcinoma (red Fig. 3.10: Red lagoons—angioma.
circle).
Fig. 3.11: Milky red areas—melanoma (arrows). Fig. 3.12: Straight vessels—squamous cell carcinoma.
•• Milky red areas: (Vascular reddening) Large blurred •• Spiral or glomerular: Vessels in a tight spiral, which
areas of milky red color. Within, we can observe other can resemble areas or globules (Fig. 3.17)
dermoscopic structures (Fig. 3.11). •• Twisted or serpent-like: With curves and lines, and
generally very irregular (Fig. 3.18)
Linear Vessels
They can be as follows: ARRANGEMENT
•• Straight: Linear, small and thin, regular or irregular This can be as follows:
(Fig. 3.12) •• Diffuse: Spreading over almost all of the lesion (Fig. 3.19)
•• Arborizing: Thick vessels that become thinner and •• Focal: Appearing in different areas (Fig. 3.20)
arborized into narrow vessels like the branches of a •• Crown: Lying in the periphery (comma-like) (Fig. 3.21)
tree (Figs. 3.13 and 3.14) •• Spoke wheel or radial: Lying in the periphery (straight
•• Comma-like: Bending or curving vessels (Fig. 3.15) linear or hairpin) (Fig. 3.22)
•• Hairpin: Vessels with a vascular knot, shaped like a •• Irregular randomly distributed: Mostly irregular linear
handle, either fine or thick (Fig. 3.16) vessels (Fig. 3.23)
Fig. 3.13: Arborizing vessels—basal cell carcinoma. Fig. 3.14: Arborizing vessels—basal cell carcinoma.
Fig. 3.15: Comma-like vessels—intradermal nevus (arrows). Fig. 3.16: Hairpin vessels—seborrheic keratosis (red circle).
Fig. 3.17: Glomerular vessels—squamous cell carcinoma (red circle). Fig. 3.18: Twisted vessels—melanoma (arrow).
Fig. 3.19: Diffuse arrangement—hemangioma. Fig. 3.20: Focal arrangement—squamous cell carcinoma (red circles).
Fig. 3.21: Crown vessels—sebaceous hyperplasia. Fig. 3.22: Radial vessels—keratoacanthoma.
Since the morphology of the vessels can be the same

for two or more types of tumors, their distribution in the
lesion is sometimes the key to the diagnosis.
•• Crown curved linear vessels: Sebaceous hyperplasia
(Fig. 3.21).
•• Dot-like vessels in a string-of-pearls or rosary distribu-
tion: Clear cell acanthoma (Fig. 3.24)
•• Focal or in-nest glomerular vessels: Squamous carci
noma in situ or Bowen disease (Figs. 3.17 to 3.20)
•• Diffuse comma-like or curvilinear vessels: Intradermal
cellular nevus (Fig. 3.25)
•• Diffuse hairpin vessels: Seborrheic keratosis (Fig. 3.26)
•• Hairpin vessels with radial peripheral distribution:
Keratoacanthoma, in which case we can also observe
Fig. 3.23: Irregular randomly distributed vessels—hypomelanotic a structureless area, formed by a yellow-whitish kera
melanoma.
totic central mass and thrombosed vessels (Fig. 3.27)
Fig. 3.24: Dot-like vessels in a string-of-pearls or rosary distribution— Fig. 3.25: Diffuse comma-like or curvilinear vessels—intradermal nevus.
clear cell acanthoma.
Fig. 3.26: Diffuse hairpin vessels—seborrheic keratosis. Fig. 3.27: Hairpin vessels with radial peripheral distribution (A) and
structureless area, formed by a yellow-whitish keratotic central mass
and thrombosed vessels (B) keratoacanthoma.
•• Arborizing vessels: Basal cell carcinoma (Figs. 3.13 and Polymorphic: This means the presence of two or more
3.14) vessel morphologic types.
•• Irregular distribution: Hypomelanotic/amelanotic mela The most frequent combination is dot-like vessels
noma (HAM) (Fig. 3.28) and linear ones in different shapes, widths, and arrange
ments, which appear on milky red areas of HAM, gener
PATTERN ally of medium thickness. In thicker HAM, on the other
hand, although the pattern is polymorphic, it is frequent
Monomorphic: Only one vessel type (Figs. 3.10 to 3.14). to observe glomerular vessels, hairpin-shaped, twisted or
Angioma, with its red areas (lacunae), is an example linear, irregular and randomly distributed over milky red
of monomorphic pattern in benign lesions. Basal cell car areas (Fig. 3.28).
cinoma with its arborizing vessels is an example of mono Diagnosis of nonpigmented cutaneous lesions is a real
morphic pattern in malignant lesions. challenge. Every pink lesion must arise suspicion of being
Table 3.2: Correlations between vessels morphology and diseases.

Main vessels morphology Disease
Arborizing vessels Basal cell carcinoma
Comma-like vessels Intradermal nevi
Congenital melanocytic nevi
Dysplastic nevi
Crown vessels Sebaceous hyperplasia
Molluscum contagiosum
Dotted and globular vessels Melanoma
Spitz nevus
Dysplastic nevus
Light-cell acanthoma (“string-of-
pearls” distribution)
Psoriasis
Squamous cell carcinoma
Stasis dermatitis
Fig. 3.28: Dot-like and linear vessels in different shapes, widths, and Warp (frequently with thrombosis)
arrangements—hypomelanotic melanoma.
Hairpin vessels: Seborrheic keratosis
Narrow (Peripheral) Keratoacanthoma
Thick Melanoma
HAM, and therefore, following the vascular pattern diag Irregular Irritated seborrheic keratosis
nostic algorithm together with other dermoscopic charac Spinal cell carcinoma
Spitz nevus
teristics of the lesion can be an invaluable tool (Table 3.2).
Lacunae Hemangiomas
Irregular lineal vessels Melanoma
SUGGESTED READING Spitz nevus
Argenziano G, Zalaudek I, Corona R, et al. Vascular struc Milky red areas/globules Melanoma
tures in skin tumors: a dermoscopy study. Arch Dermatol. Polymorphic vessels Melanoma
2004;140:1485-9.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina:
Ediciones Journal; 2012. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of non-pig
Kreusch JF. Vascular patterns in skin tumors. Clin Dermatol. mented skin tumors. Boca Raton, FL: CRC Press; 2016.
2002;20:248-54. Zalaudek I, Kreusch J, Giacomel G, et al. How to diagnose non
Malvehy J, Puig S. Principios de dermatoscopia. España: Der pigmented skin tumors: a review of vascular structures seen
moscop; 2009. with dermoscopy. Part I. Melanocytic skin tumors. JAAD.
Pizzichetta MA, Talamini R, Stranganelli I, et al. Amelanotic/ 2010;63:361-74.
hypomelanotic melanoma: clinical and dermoscopic fea Zalaudek I, Kreusch J, Giacomel G, et al. How to diagnose non
tures. Br J Dermatol. 2004;150:1117-24. pigmented skin tumors: a review of vascular structures seen
Zaballos P, Ara M, Puig S, et al. Dermoscopy of sebaceous hyper with dermoscopy. Part II. Nonmelanocytic skin tumors.
plasia. Arch Dermatol. 2005;141:808. JAAD. 2010;63:377-86.
DERMOSCOPY:
A TWO-STEP PROCEDURE 4
Horacio A Cabo
”Dermoscopic examination can be performed in two steps.
The first step aims at determining whether we are in the presence of a melanocytic lesion or a
nonmelanocytic one. If it is a melanocytic lesion, we move on to the second step, which means
determining if it is a melanoma, a benign melanocytic lesion or a suspicious or atypical melanocytic lesion.”
Dermoscopy: A Two-Step Procedure 33
Dermoscopic examination can be performed in two steps. The only requirements to use them are sound knowledge
The first step aims at determining whether we are in the and good mastery in the chosen method. Table 4.2 lists the
presence of a melanocytic lesion or a nonmelanocytic best-known diagnosis methods.
one. If it is a melanocytic lesion, we move on to the sec
ond step, which means determining if it is a melanoma,
a benign melanocytic lesion or a suspicious or atypical Table 4.1: Diagnosis algorithm.
melanocytic lesion. 1. Criteria for melanocytic lesions:
• Pigment network
• Brown globules
FIRST STEP • Streaks or projections
• Homogeneous blue pigmentation
In the first step, it is very useful to apply the diagnosis algo • Parallel pattern
rithm as discussed in Table 4.1 and Figures 4.1 to 4.21.
2. Criteria for seborrheic keratosis:
It may happen that we are in the presence of a pig
• Multiple pseudocysts
mented lesion, without the criteria for melanocytic lesions • Multiple pseudo follicular openings
nor for nonmelanocytic ones. This is an unspecified lesion • Fissures and ridges (brain-like appearance)
without definite criteria. The majority of these cases are • Vascular pattern with peripheral hairpin vessels
atypical melanocytic nevi or melanoma. 3. Criteria for basal cell carcinoma:
Recently, a modification has been proposed to the • Vascular pattern:
–– Large arborizing vessels
diagnosis algorithm for the first step, by adding the vas
–– Fine truncated vessels
cular patterns (Figs. 4.5 and 4.6) which were described in • Blue-gray pigmentation
Chapter 3. • Leaf-like or digit-like structures
• Blue-gray globules: Large, ovoid, or small and multiple
• Spoke-wheel areas
SECOND STEP • Ulcerations
In this step, we must examine the different criteria and 4. Criteria for vascular lesions:
structures, in order to determine if it is a benign lesion or • Red or blue-red lagoons
a melanoma. 5. Vascular structures associated with nonmelanocytic lesions
There are different diagnosis methods, which are des
6. Vascular structures associated with melanocytic lesions
cribed in detail in Chapter 10.
These algorithms are very similar as regards sensitiv 7. Absence of the above criteria: Rule out melanocytic lesion
without the classical criteria
ity and specificity, which make them all extremely useful.
Fig. 4.1: First step: Melanocytic lesions. Fig. 4.2: Second step: Seborrheic keratosis.
Fig. 4.3: Third step: Basal cell carcinoma. Fig. 4.4: Fourth step: Hemangiomas.
Fig. 4.5: Fifth step: Vascular patterns for nonmelanocytic lesions. Fig. 4.6: Sixth step: Vascular patterns for melanocytic lesions.
Fig. 4.7: Seventh step: In the absence of all the previous criteria, rule Fig. 4.8: Pigment network—junction nevus.
out a melanocytic lesion.
Fig. 4.9: Brown globules—compound nevus. Fig. 4.10: Streaks and projections—Spitz nevus.
Fig. 4.11: Homogeneous blue pigmentation—blue nevus. Fig. 4.12: Parallel pattern—acral nevus.
Fig. 4.13: Follicular pseudocysts and pseudo-openings—seborrheic Fig. 4.14: Fissures and ridges (brain-like patterns)—seborrheic
keratosis. keratosis.
Fig. 4.15: Arborizing vessels—basal cell carcinoma. Fig. 4.16: Blue-gray globules—basal cell carcinoma.
Fig. 4.17: Spoke-wheel areas (arrows)—basal cell carcinoma. Fig. 4.18: Ulcerations (arrow)—basal cell carcinoma.
Fig. 4.19: Leaf-like structures (arrows)—basal cell carcinoma. Fig. 4.20: Red-blue lagoons (arrow)—hemangioma.
Table 4.2: Diagnostic methods for melanocytic lesions.

Pattern analysis (Pehamberger)
ABCD rule (Stolz)
11-point checklist method (Menzies)
7-point checklist method (Argenziano)
3-point checklist (Soyer)
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat

tern Analysis 2011 Facultas Verlags- und Buchhandels AG
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea
Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
Taylor & Francis; 2005.
Fig. 4.21: Unspecific lesion—melanoma. Marghoob A, Braun R. Proposal for a revised 2-step algorithm
for the classification of lesions of the skin using dermoscopy.
Arch Dermatol. 2010;146:426-8.
Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
SUGGESTED READING copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
Company; 1996.
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas
Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
of Dermoscopy. Milán: EDRA Medical Publishing & New
Media; 2000.
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
2000. mented Skin Lesions. An Atlas Based on the Consensus Net
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Ediciones Journal; 2012. New Media; 2001.
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermato
Guide, 2nd edition. New York: McGraw-Hill Education; 2015. scopy. USA: Blackwell Science; 1994.
Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
(MOABT). New York: Elsevier Ltd; 2004. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
NONMELANOCYTIC
LESIONS 5
Horacio A Cabo
”The dermoscopic image of SK is rather different when using
polarized-light or nonpolarized-light dermoscopes.
The latter allow a better visualization of milia-like cysts.
Basal cell carcinomas are pink but sometimes BCCs are pigmented, due to melanocyte hyperplasia.
In these cases, BCC can be considered a melanoma simulator.
Squamous cell carcinoma show hyperkeratosis usually located in the central part
and also white circles surrounding the dilated infundibulum.”
Nonmelanocytic Lesions 41
5.1 SEBORRHEIC KERATOSIS

Horacio A Cabo
Seborrheic keratoses (SKs) are benign skin tumors that DERMOSCOPIC CRITERIA
appear toward middle aged and occasionally in young
•• Milia-like cysts
people. They are very frequent and show preferably on the
•• Pseudofollicular openings (irregular ridges)
face and trunk. However, it is not uncommon to find them •• Fissures and ridges (brain-like appearance)
in different areas of the cutaneous surface, except palms •• Vascular pattern
and soles. Generally, they are multiple and their size is
variable—between a few millimeters and some centime- Milia-like Cysts (Fig. 5.1)
ters. The color is not defined; it can be light brown, yellow- They are circular structures, white-yellow in color and
ish brown, dark brown, or black. small in size (0.1–1 mm). In very big or verrucous SKs, the
Initially, SKs are flat with well-demarcated edges. As size can be larger, while the shape may not be circular.
From a histopathological point of view, we can observe
they evolve, they rise and acquire a warty appearance,
horny pseudocysts in the epidermis that do not communi-
which is a characteristic (stuck-on appearance). In general,
cate with the cutaneous surface (Fig. 5.2).
clinical diagnosis of SK is not difficult. Nevertheless, it is
necessary to distinguish the pigmented superficial variety Pseudofollicular Openings
from lentigo malignant melanoma, while the raised vari- (Irregular Ridges) (Figs. 5.3 and 5.4)
ants can be taken for atypical nevi and melanoma. The These structures are yellowish, light brown, dark brown,
irritated forms of SK can also prove difficult for the clinical or black, circular in shape, and of small size, presenting
diagnosis. In doubtful cases, dermoscopy optimizes clini the typical appearance of a pore or a comedo. In large SKs,
cal diagnosis more than for any other pigmented lesion, their size can be even bigger and the shape is irregular.
except hemangioma. From a histopathological point of view, they are horny
pseudocysts that reach the cutaneous surface and com-
In highly verrucous varieties, it is impossible to identify
municate with it.
characteristic structures for SK due to the high orthokera-
tosis present in these lesions. Fissures and Ridges (Brain-Like
The two typical criteria and characteristics of SK are Appearance) (Figs. 5.5 and 5.6)
milia-like cysts and follicular openings, although other These are variants in size and shape of follicular pseu-
less specific criteria can also be observed. All of these cri- do-openings and their appearance resembles the surface
teria are described hereunder. of the brain.
Fig. 5.1: Seborrheic keratosis. The arrows show the millia-like cysts. Fig. 5.2: Seborrheic keratosis. Histological image, showing the horny
pseudocysts without communication with the cutaneous surface
(arrow).
Fig. 5.3: Seborrheic keratosis. The arrows show pseudofollicular Fig. 5.4: Seborrheic keratosis. Histological images showing the horny
openings. pseudocysts with communication with the cutaneous surface (arrow).
Fig. 5.5: Seborrheic keratosis. Brain-like appearance. Fig. 5.6: Seborrheic keratosis. Brain-like appearance.
Vascular Pattern (Figs. 5.7 to 5.12) ADDITIONAL OBSERVATION CRITERIA

Hairpin vessels in the periphery of the lesions. Additionally, the following criteria can be observed:
•• Pigmented network (exceptionally, it is possible to
HISTOPATHOLOGY observe a fine delicate pigment network on the periph-
ery of the lesion (Figs. 5.13 to 5.15).
From a histopathological point of view, SKs are epidermal
•• Blue-white veil: This appears in lesions with height-
lesions composed of little basaloid cells, pigmented or ened orthokeratosis (Fig. 5.16).
not, with an excess keratin production that tends to form •• Fat fingers: These are thick digitate linear, curvilinear,
horny cysts. branched, or oval/circular dermoscopic structures at
Some communicate with the cutaneous surface (fol- the periphery of the lesion. They represent the gyri of
licular pseudo-openings) and others do not (milia-like their cerebriform surfaces (Figs. 5.17 and 5.18).
cysts). •• Regression: Some SKs may show signs of regression,
Irregular ridges and fissures are variants in size usually after traumas (Figs. 5.19 to 5.21).
and shape of the follicular pseudo-openings (Figs. 5.2 •• Blue globular pattern: Some SKs can show this pattern
to 5.4). (acanthotic SKs) (see Fig. 5.39).
Fig. 5.7: Seborrheic keratosis. Hairpin vessels (red arrows); millia-like Fig. 5.8: Seborrheic keratosis. Hairpin vessels (red arrows), millia-like
cysts (black arrows). cysts (black arrow), pseudofollicular openings (white arrow).
Fig. 5.9: Seborrheic keratosis. Hairpin vessels. Fig. 5.10: Seborrheic keratosis. Hairpin vessels.
Fig. 5.11: Seborrheic keratosis. Hairpin vessels; close-up view of Figure Fig. 5.12: Seborrheic keratosis. Hairpin vessels.
5.10.
Fig. 5.13: Seborrheic keratosis with pigment network (black arrow) Fig. 5.14: Seborrheic keratosis with pigment network.
and millia-like cysts (red arrow).
Fig. 5.15: Seborrheic keratosis with pigment network. Fig. 5.16: Seborrheic keratosis with blue veil (arrow).
Fig. 5.17: Seborrheic keratosis. The arrow shows the fat fingers. Fig. 5.18: Seborrheic keratosis. The arrow shows the fat fingers.
Fig. 5.19: Seborrheic keratosis with regression. Fig. 5.20: Seborrheic keratosis with regression.
Fig. 5.21: Seborrheic keratosis with regression. Fig. 5.22: Seborrheic keratosis—polarized light.
Fig. 5.23: Seborrheic keratosis—polarized light.
Polarized Light Versus Nonpolarized Light

The dermoscopic image of SK is rather different when The latter allow a better visualization of milia-like cysts
using polarized-light or non polarized-light dermoscopes. (Figs. 5.22 to 5.38).
Fig. 5.24: Seborrheic keratosis—polarized light. Fig. 5.25: Seborrheic keratosis—nonpolarized light.
Fig. 5.26: Seborrheic keratosis—nonpolarized light. Fig. 5.27: Seborrheic keratosis—nonpolarized light.
Fig. 5.28: Seborrheic keratosis—nonpolarized light. Fig. 5.29: Seborrheic keratosis—nonpolarized light.
A B A B
Figs. 5.30A and B: Seborrheic keratosis. (A) The image captured Figs. 5.31A and B: Seborrheic keratosis. (A) The image captured with
with a polarized light dermoscope and (B) the image captured with a a polarized light dermoscope; (B) the image captured with a nonpola
nonpolarized light dermoscope. rized light dermoscope.
A B
A B
Figs. 5.32A and B: Seborrheic keratosis. (A) The image captured Figs. 5.33A and B: Seborrheic keratosis. (A) The image captured
with a polarized light dermoscope and (B) the image captured with a with a polarized light dermoscope; (B) the image captured with a
nonpolarized light dermoscope. nonpolarized light dermoscope.
A B A B
Figs. 5.34A and B: Seborrheic keratosis. (A) The image captured with Figs. 5.35A and B: Seborrheic keratosis. (A) The image captured with
a polarized light dermoscope; (B) image captured with a nonpolarized a polarized light dermoscope; (B) the image captured with a nonpola
light dermoscope. rized light dermoscope.
A B
A B
Figs. 5.36A and B: Seborrheic keratosis. (A) The image captured with Figs. 5.37A and B: Seborrheic keratosis. (A) The image captured with
a polarized light dermoscope; (B) the image captured with a nonpo a polarized light dermoscope; (B) the image captured with a nonpo
larized light dermoscope. larized light dermoscope.
A B
Figs. 5.38A and B: Seborrheic keratosis. (A) The image captured with Fig. 5.39: Blue globular pattern.
a polarized light dermoscope; (B) the image captured with a non
polarized light dermoscope.
SUGGESTED READING Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:

Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros-
of Dermoscopy. Milán: EDRA Medical Publishing & New copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
Media; 2000. Company; 1996.
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; Rabinovitz H, Kopf A. Dermoscopy: a practical guide. Miami:
2000. American Academy of Dermatology; 1999.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Roberti V, Devirgiliis V, Curzio M, et al. The blue globular pattern
Ediciones Journal; 2012. in dermoscopy. Dermatology. 2013;226:260-6.
Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig-
(MOABT). New York: Elsevier Ltd; 2004. mented Skin Lesions. An Atlas Based on the Consensus Net
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Guide, 2nd edition. New York: McGraw-Hill Education; 2015. New Media; 2001.
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat- Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos-
tern Analysis. Vienna, Austria: facultas.wuv; 2011. copy. Berlin, Germany: Blackwell Science; 1994.
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea- Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
ciones Gráficas; 2009. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
5.2 SOLAR LENTIGO

Horacio A Cabo
Solar lentigo and flat seborrheic keratosis (SK) are consid- Moth-Eaten Border (Figs. 5.43 to 5.45)
ered the same lesion. Concave edge of the lesion resembling the bite of a moth.
Jelly Sign (Figs. 5.46 to 5.49)
DERMOSCOPIC CRITERIA Light brown or yellowish in color, it resembles a very thin
FOR SOLAR LENTIGO (FLAT SK) layer of jelly which has dried or a film covering the surface
of the skin.
Fingerprint-Like Structures (Figs. 5.40 to 5.43)
These are brown structures, made up of fine parallel INKSPOT LENTIGO
lines in fingerprint fashion. They are usually found in the Inkspot lentigo deserves special attention due to its clini-
peripheral part of the lesion. cal and dermoscopic characteristics.
Fig. 5.40: Solar lentigo. The arrows show the fingerprint-like structures. Fig. 5.41: Solar lentigo. The arrows show the fingerprint-like structures.
Fig. 5.42: Solar lentigo. The arrows show the fingerprint-like structures. Fig. 5.43: Solar lentigo. Red arrow: moth-eaten border. Black arrows:
fingerprint-like structures.
Fig. 5.44: Solar lentigo. The arrows show the moth-eaten border. Fig. 5.45: Solar lentigo. Red arrows: moth-eaten border. Black arrow:
fingerprint-like structures.
Fig. 5.46: Solar lentigo. The arrow shows the jelly sign. Fig. 5.47: Solar lentigo. The arrows show the jelly sign.
Fig. 5.48: Solar lentigo. The arrow shows the jelly sign. Fig. 5.49: Solar lentigo. The arrow shows the jelly sign.
Fig. 5.50: Solar lentigo. Inkspot lentigo. Fig. 5.51: Solar lentigo. Inkspot lentigo.
Fig. 5.52: Solar lentigo. Inkspot lentigo. Fig. 5.53: Solar lentigo. Inkspot lentigo.
It generally appears in highly photodamaged skin, as

a small lesion, with flat smooth surface and black color
(resembling an inkspot, hence its name).
Under dermoscopic examination, we can observe a
black pigment network, thickened and irregular, which
may lead the less-experienced observers to a misdiagnosis
of melanoma (Figs. 5.50 and 5.51).
On occasion, solar lentigo can show pigment network
and make it difficult to reach a differential diagnosis from
melanocytic lesions (Figs. 5.52 to 5.55).
Also, solar lentigo may occasionally show pigmenta-
tion of the follicular opening, sometimes asymmetric, and
two brown concentric circles, which may render it difficult
Fig. 5.54: A 52-year-old female patient with sun damage and multiple to make the differential diagnosis from malignant lentigo
lentigos on chest (A-B-C). and pigmented actinic keratosis (Figs. 5.56 to 5.62).
Fig. 5.55: Solar lentigo with reticular pattern (A). Fig. 5.56: Solar lentigo with reticular pattern (B).
Fig. 5.57: Solar lentigo with reticular pattern (C). Fig. 5.58: Solar lentigo: red arrows: asymmetric pigmentation of the
follicular openings; black arrow: circle within a circle; white arrow:
brown pigmentation of the follicular openings.
Fig. 5.59: Solar lentigo: red arrow: asymmetric pigmentation of the Fig. 5.60: Solar lentigo: red arrows: asymmetric pigmentation of the
follicular openings; black arrow: circle within a circle; white arrow: follicular openings; black arrow: circle within a circle; white arrow:
brown pigmentation of the follicular openings. brown pigmentation of the follicular openings.
Fig. 5.61: Solar lentigo: red arrow: asymmetric pigmentation of the Fig. 5.62: Solar lentigo: red arrow: asymmetric pigmentation of the
follicular openings; black arrow: circle within a circle; white arrow: follicular openings; black arrows: circle within a circle; white arrow:
brown pigmentation of the follicular openings. brown pigmentation of the follicular openings.

Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
2000. Company; 1996.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
Ediciones Journal; 2012. American Academy of Dermatology; 1999.
(MOABT). New York: Elsevier Ltd.; 2004. mented Skin Lesions. An Atlas Based on the Consensus Net
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat- Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos-
tern Analysis. Vienna, Austria: facultas.wuv; 2011. copy. Berlin, Germany: Blackwell Science; 1994.
Lallas A. Dermoscopy in general dermatology, Dermatol Clin. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-Pig-
2013;31:679-694. mented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
5.3 BASAL CELL CARCINOMA

Horacio A Cabo
Basal cell carcinoma (BCC) is the most frequent of all malig Since BCC is not a melanocytic lesion, we rarely observe
nant skin tumors and cancers that may affect human pigment network (Figs. 5.69 and 5.70); nevertheless,
beings. This malignant tumor does not generally metas- its absence does not rule BCC out. In consequence, besides
tasize and its incidence increases with sun exposure and the lack of pigment network, it is necessary to detect some
over the age of 40. It is more frequent in men and less com- of the following criteria:
mon in dark complexions. In general, the lesions are pink •• Vascular pattern: This can be the only criterion present
but sometimes BCCs are pigmented, due to melanocyte in nonpigmented BCC. It is characterized by the pres-
hyperplasia. In these cases, BCC can be considered a mel- ence of two vessel types.
anoma simulator (Figs. 5.63 and 5.64). –– Thick vessels with numerous branching, or arbo-
From a histologic point of view, we can observe glob- rizing vessels (Figs. 5.71 to 5.73)
–– Narrow truncated vessels (Figs. 5.74 to 5.78)
ules or basaloid cell strings distributed in the periphery
forming a palisade. In general, it is possible to visualize
fibrovascular stroma with abundant mucin surrounding
the tumor (Fig. 5.65).
DERMOSCOPIC CRITERIA FOR BASAL

CELL CARCINOMA
Basal cell carcinoma can present classical criteria, non-
classical criteria (generally the onset of classical criteria)
and, on occasion, highly pigmented BCCs can show crite-
ria similar to those of melanocytic lesions.
Classical Criteria
Basal cell carcinoma typically presents three well-defined
criteria: arborizing vessels, blue–gray pigmentation, and
ulcerations (Figs. 5.66 to 5.68). Fig. 5.63: Basal cell carcinoma clinical image.
Fig. 5.64: Clinical image of a pigmented basal cell carcinoma. Fig. 5.65: Histological image showing the basaloid cell strings distrib-
uted in the periphery forming a palisade (red arrow) and fibrovascular
stroma with abundant mucin surrounding the tumor (black arrow).
Fig. 5.66: Basal cell carcinoma with the three major criteria: arborizing Fig. 5.67: Basal cell carcinoma with the three major criteria: arborizing
vessels (red arrow), blue-gray pigmentation (black arrow), ulceration vessels (red arrow), blue-gray pigmentation (black arrow), ulceration
(white arrow). (white arrow).
Fig. 5.68: Basal cell carcinoma with the three major criteria: arborizing Fig. 5.69: Basal cell carcinoma with pigment network (arrow).
vessels (red arrow), blue-gray pigmentation (black arrow), ulceration
(white arrow).
Fig. 5.70: Basal cell carcinoma with pigment network (arrows). Fig. 5.71: Basal cell carcinoma. Arborizing vessels.
Fig. 5.72: Basal cell carcinoma. Arborizing vessels.
A B
C D
Figs. 5.73A to D: Basal cell carcinoma. Arborizing vessels.
Fig. 5.74: Basal cell carcinoma. Narrow truncated vessels or narrow Fig. 5.75: Basal cell carcinoma. Narrow truncated vessels or narrow
short telangiectasia. short telangiectasia.
A B
C D
Figs. 5.76A to D: Basal cell carcinoma. Narrow truncated vessels or narrow short telangiectasia.
Fig. 5.77: Basal cell carcinoma. Narrow truncated vessels or narrow Fig. 5.78: Basal cell carcinoma. Narrow truncated vessels or narrow
short telangiectasia (arrow). short telangiectasia (arrow).
A B
C D
Figs. 5.79A to D: Basal cell carcinoma. Leaf-like structures (arrows).
•• Blue–gray pigmentation: Depending on the pigment –– Leaf-like structures (Figs. 5.79 to 5.83): Also known
distribution in the lesion, we can observe the following as maple-leaf structures. They are usually located
structures: in the periphery of the lesion, blue-gray in color
and observable in pigmented BCCs.
A B
C D
A B
Figs. 5.81A and B
C D
A B
C D
A B
C D
Histologically they are the result of melanin pigment

due to hyperplastic melanocytes.
–– Large blue-gray ovoid nests or globules: These are
also due to an increase in melanin and to hyper-
plastic melanocytes. They are globular or ovoid
formations with sharp edges and homogeneous
coloration (Figs. 5.84 to 5.88).
–– Multiple blue-gray globules: These have the same
origin as the structures previously mentioned, but
are smaller in size (Figs. 5.89 and 5.90).
–– Spoke-wheel areas or radial areas: These are well-
circumscribed radial projections, brown, blue, or
Fig. 5.84: Basal cell carcinoma. Large blue-gray ovoid nests or glob- gray in color, projecting from a central axis, gen
ules (arrow).
erally darker (Figs. 5.91 to 5.94).
Fig. 5.85: Basal cell carcinoma. Large blue-gray ovoid nests or glob- Fig. 5.86: Basal cell carcinoma. Large blue-gray ovoid nests or glob-
ules (arrow). ules (arrow).
Fig. 5.87: Basal cell carcinoma. Large blue-gray ovoid nests or glob- Fig. 5.88: Basal cell carcinoma. Large blue-gray ovoid nests or glob-
ules (arrow). ules (arrow).
Fig. 5.89: Basal cell carcinoma. Multiple blue-gray globules (arrow). Fig. 5.90: Basal cell carcinoma. Multiple blue-gray globules (arrow).
Fig. 5.91: Basal cell carcinoma. Spoke-wheel areas (arrow). Fig. 5.92: Basal cell carcinoma. Spoke-wheel areas (arrows).
Fig. 5.93: Basal cell carcinoma. Spoke-wheel areas (arrow). Fig. 5.94: Basal cell carcinoma. Spoke-wheel areas (arrows).
Fig. 5.95: Basal cell carcinoma. Ulceration (arrow). Fig. 5.96: Basal cell carcinoma. Ulceration (arrows).
•• Ulcerations: These can be single or multiple and in If the aforementioned criteria are employed in the
different sizes. Their coloration can be red, blue, or course of the elaboration of the BCC dermoscopic diagno-
black, depending on tumor pigmentation (Figs. 5.95 sis, the sensitivity of the method is 93%, while the speci
to 5.99). ficity is 89%.
A B
C D
Figs. 5.97A to D: Basal cell carcinoma. Ulceration (arrows).
A B
Figs. 5.98A and B
C D
Figs. 5.98A to D: Basal cell carcinoma. Ulceration (arrows).
Fig. 5.99: Basal cell carcinoma. Ulceration (arrow). Fig. 5.100: Basal cell carcinoma multiple blue-gray dots (arrow).
Nonclassic Criteria Criteria Similar to those

These criteria, like the classic ones, are related to pigmen- of Melanocytic Lesions
tation, vessels, and the loss of cutaneous surface. Highly pigmented BCCs, or those observed in people of
•• Blue-gray pigmentation very dark skin, may present dermoscopic characteristics
–– Multiple focalized blue-gray dots: Very small areas similar to the dermoscopy criteria of melanocytic lesions.
with blue-gray pigment (Figs. 5.100 and 5.101). These true melanoma simulators often force us to perform
–– Concentric structures: Round areas with a darker a histopathologic study (Fig. 5.109; Table 5.2):
center (Figs. 5.102 to 5.106). •• Multiple dots/brown-black globules (Fig. 5.110)
•• Narrow short telangiectasia (see Figs. 5.74 to 5.78) •• Structures similar to blue-white veil (see Fig. 5.84)
•• Small multiple erosions (Figs. 5.107 and 5.108) •• Nonarborizing vessels (Fig. 5.111)
(Table 5.1) •• Pigment network (see Figs. 5.69 and 5.70)
Fig. 5.101: Basal cell carcinoma multiple blue-gray dots (arrows). Fig. 5.102: Basal cell carcinoma concentric structures (arrows).
Fig. 5.103: Basal cell carcinoma concentric structures (arrows).
A B
Figs. 5.104A and B
C D
Figs. 5.104A to D: Basal cell carcinoma concentric structures (arrows).
Fig. 5.105: Basal cell carcinoma concentric structures (arrow).
A B
Figs. 5.106A and B
C D
Figs. 5.106A to D: Basal cell carcinoma concentric structures (arrows).
Fig. 5.107: Basal cell carcinoma small multiple erosions (arrows). Fig. 5.108: Basal cell carcinoma small multiple erosions (arrow).
Table 5.1: Basal cell carcinoma.

Classic patterns Nonclassic patterns
Blue-gray pigmentation Blue-gray pigmentation
• Leaf-like structures • Multiple focalized blue-gray
dots
• Large blue-gray ovoid nests • Concentric structures
• Multiple blue-gray globules
• Spoke-wheel areas
Arborizing vessels Narrow short telangiectasia
Ulceration Multiple small erosions
Fig. 5.109: Clinical and dermoscopic images of a pigmented basal cell

carcinoma simulating a melanoma.
Table 5.2: Basal cell carcinoma.

Criteria similar to those of melanocytic lesions
• Multiple Brown-black dots/globules
• Structures resembling blue-white veil
• Nonarborizing vessels
• Pigment network
• Multiple blue-gray dots (pepper-like)
• Radial projections or pseudopods
Fig. 5.110: Basal cell carcinoma: multiple dots/brown-black globules

(arrows).
Fig. 5.111: Basal cell carcinoma with nonarborizing vessels (arrow). Fig. 5.112: Basal cell carcinoma with multiple blue-gray dots (pepper-
like) (arrow).
•• Multiple blue-gray dots (pepper-like) (Fig. 5.112)

•• Radial projections or pseudopods (Fig. 5.113 and
Table 5.2)
White shiny or crystalline structures: These have been
described in recent years (Figs. 5.114 to 5.116):
•• They are bright lineal streaks of pearly white color.
•• They are invisible to the naked eye or the nonpolarized
light of the dermatoscope.
•• Observable in lesions with an increased amount of
collagen. The collagen streaks are birefringent, causing
a quick randomization of the polarized light.
•• It is a dynamic polarized dermoscopy:
–– By rotating the dermoscope but keeping it in con-
Fig. 5.113: Basal cell carcinoma with radial projections or pseudopods tact with the cutaneous surface, the direction of
(arrows).
the crystalline structures can be changed.
Fig. 5.114: Basal cell carcinoma with white shiny or crystalline struc-
tures (arrows).
A B
C D
Figs. 5.115A to D: Basal cell carcinoma with white shiny or crystalline structures (arrows).

Ediciones Journal; 2012.
Felder S, Rabinovitz H, Oliviero M, et al. Dermoscopic pattern of
pigmented basal cell carcinoma, blue-white variant. Dermatol
Surg. 2006;32:569-70.
Giacomel J, Zalaudek I. Dermoscopy of superficial basal cell car-
cinoma. Dermatol Surg. 2005;31:1710-3.
Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials
A B (MOABT). New York: Elsevier Ltd; 2004.
Guide, 2nd edition. New York: McGraw-Hill Education; 2015.
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pattern
Analysis 2011 Facultas Verlags- und Buchhandels AG facultas
wuv Universitätsverlag, Austria www.facultas.wuv.at.
Lallas A. Dermoscopy in general dermatology. Dermatol Clin.
2013;3:679-94.
Lallas A, Tzellos T, Kyrgidis A, et al. Accuracy of dermoscopic
Figs. 5.116A and B: Basal cell carcinoma: (A) image captured with
criteria for discriminating superficial from other subtypes of
nonpolarized light—no crystalline structures are observed; (B) image basal cell carcinoma. J Am Acad Dermatol. 2014;70:303-11.
captured with polarized light where crystalline structures are observed Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-
(arrow). ciones Gráficas; 2009.
Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micro
–– Because of the angular dependence of the polari scopy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
zed light, reflecting the nonrandom distribution of Company; 1996.
the collagen fibers in the dermis. Menzies S, Westerhoff K, Rabinivitz H, et al. Surface micros-
•• They can be found in any type of BCC and also in der- copy of pigmented basal cell carcinoma. Arch Dermatol.
2000;136:1012-6.
matofibroma, melanoma, Spitz nevus, and scars. Menzies SW. Dermoscopy of pigmented basal cell carcinoma.
Clin Dermatol. 2002;20:268-9.
SUGGESTED READING Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig-
of Dermoscopy. Milán: EDRA Medical Publishing & New mented Skin Lesions. An Atlas Based on the Consensus Net
Media; 2000. Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Altamura D, Menzies S, Argenziano G, et al. Dermatoscopy of New Media; 2001.
basal cell carcinoma: Morphologic variability of global and Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos-
local features and accuracy of diagnosis. J Am Acad Derma- copy. Germany: Blackwell Science; 1994.
tol. 2010;62:67-75. Tschandl P, Rosendahl C, Kittler H. Dermoscopy of flat pigmented
Balagula Y, Braun RP, Rabinovitz HS, et al. The significance of facial lesion. J Eur Acad Dermatol Venereol. 2015;29(1):120-7.
crystalline/chrysalis structures in the diagnosis of mela- Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
nocytic and nonmelanocytic lesions. J Am Acad Dermatol. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
2012;67:194.e1-8. Zalaudek I, Cabo H, Ferrara G, et al. Dermoscopic-pathologic
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; correlation in an unusual case of pigmented basal cell carci-
2000. noma. Dermatol Surg. 2006;32:1509-12.
5.4 ANGIOMAS AND ANGIOKERATOMAS

Horacio A Cabo
ANGIOMAS to dilated blood vessels in the dermis. Their metaphoric

name is “lacunae” and they may vary in size and color
In general, a clinical diagnosis is enough for the majority
within the same lesion (Figs. 5.117 to 5.126).
of hemagiomas and vascular malformations, although in
If there are thrombosed vessels, we can observe black
some cases they can be misdiagnosed as other lesions or
areas (Figs. 5.127 and 5.128).
even suspected of being melanomas. It is here that der-
The dermoscopic criteria for the diagnosis of hema
moscopy plays a very important role.
The most frequent dermoscopic criterion is the presence ngioma are as follows:
of well-demarcated areas, red or blue-red, blue-black or •• Absence of pigmented structures, such as pigment
brown, which almost always correspond histologically network, globules and/or branched streaks.
Fig. 5.117: Angioma: well-demarcated lacunae on a blue–red pigment Fig. 5.118: Angioma: well-demarcated lacunae on a blue–red pigment
background (arrows). background without any dermoscopic structures within (arrows).
background without any dermoscopic structures within (arrows). background without any dermoscopic structures within (arrows).
Fig. 5.127: Thrombosed or traumatized angioma. Fig. 5.128: Thrombosed or traumatized angioma.
Fig. 5.129: Angiokeratoma. Fig. 5.130: Angiokeratoma.
•• Well-demarcated lacunae on a blue-red pigment back- thrombosis. Early lesions have minimal hyperkeratosis
ground without any dermoscopic structures within. and consist of round or oval lacunae, well demarcated,
red or blue-red; therefore, they are very similar to, and on
Angiokeratomas
occasion indistinguishable from, hemangiomas (Figs. 5.129
The solitary angiokeratoma may clinically be a melanoma
to 5.132).
simulator. It develops by superficial telangiectasia in the
Later-stage angiokeratomas contain multiple lacunae
papillary dermis, and is generally due to traumatism with
with the characteristic blue-red or blue-black color, though
reactive hyperkeratosis. It appears in youngsters and
darker. However, these lacunae are not well demarcated
adults, more frequently in the lower extremities, although
it can also manifest in the upper limbs and trunk. and often lie on a white-yellowish background, due to epi-
At an early stage, the lesions are elevated, small and dermal acanthosis and hyperkeratosis.
dark red or purple. As they evolve, they acquire a blue– When thrombosed or traumatized, there are homoge-
black color with hyperkeratosis. They are asymptomatic neous and confluent areas of blue-black pigment that sim-
but may bleed and crust if traumatized or thrombosed. ulate a melanoma (Fig. 5.133).
Their dermoscopic appearance also varies depending Dermoscopic criteria for angiokeratoma can be syn-
on their time of evolution and the presence or absence of thesized as follows:
Fig. 5.131: Angiokeratoma. Fig. 5.132: Angiokeratoma.
Fig. 5.133: Angiokeratoma. Fig. 5.134: Targetoid hemosiderotic hemangioma.
•• Absence of pigmented structures (pigmented net

work, globules, or branched streaks)
•• Lacunae less demarcated than in hemangiomas
•• Acanthosis and hyperkeratosis may show white-
yellowish areas.
Targetoid Hemosiderotic
Hemangioma
It is an uncommon, vascular, benign solitary lesion that
can be misdiagnosed as other tumors including melano-
mas.
Dermoscopy features: Red or dark lacunae and a peri
pheral circular reddish violaceous or brown homogeneous
Fig. 5.135: Targetoid hemosiderotic hemangioma. area (Figs. 5.134 and 5.135).

Argenziano G, Zalaudek I, Corona R, et al. Vascular struc- copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
tures in skin tumors. A dermoscopy study. Arch Dermatol. Company; 1996.
2004;140:1485-9. Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; 2000. American Academy of Dermatology; 1999.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Schiller PI. Angiokeratomas: an update. Dermatology. 1996;193:
Ediciones Journal; 2012. 275-82.
(MOABT). New York: Elsevier Ltd.; 2004. mented Skin Lesions. An Atlas Based on the Consensus Net
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos-
tern Analysis 2011 Facultas Verlags- und Buchhandels AG copy. Germany: Blackwell Science, 1994.
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at. Zaballos P, Daufí C, Puig S, et al. Dermoscopy of solitary angio
Kreusch J. Vascular patterns in skin tumors. Clin Dermatol. keratomas: a morphological study. Arch Dermatol. 2007;
2002;20:248-54. 143(3):318-25.
Lallas A. Dermoscopy in general dermatology. Dermatol Clin. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-Pig-
2013;3:679-94. mented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
5.5 DERMATOFIBROMA
Horacio A Cabo
Dermatofibroma is a frequent benign fibrohistiocytic epidermis covering the lesion is usually hyperplastic, with
tumor, which usually manifests clinically as an elevated elongated epidermal ridges and hyperpigmentation in
nodule, firm, of variable coloration (from pinkish to the basal layer.
brownish) localized preferably in the lower extremities
Clinical diagnosis of dermatofibroma is simple and
of young adults. Under lateral compression, a depression
dermoscopy helps with the more uncommon forms.
appears called “dimple sign.”
Histology shows a dermal nodular proliferation of Dermoscopic pattern (Figs. 5.136 to 5.143):
fibroblasts and histiocytes accompanied by an increase in •• Delicate peripheral pigment network
the number and the thickness of the collagen fibers. The •• Central white patch
Fig. 5.136: Dermatofibroma: delicate peripheral pigment network Fig. 5.137: Dermatofibroma: delicate peripheral pigment network
(black arrow) and central white patch (red arrow). (black arrow) and central white patch (red arrow). Round grayish or
brown (globule-like) areas in the central part (white arrow).
(black arrow) and central white patch (red arrow). Round grayish or (black arrow) and central white patch (red arrow). Round grayish or
brown (globule-like) areas in the central part (white arrow). brown (globule-like) areas in the central part (white arrow).
(black arrow) and central white patch (red arrow). Round grayish or (black arrow) and central white patch (red arrow). Round grayish or
brown (globule-like) areas in the central part (white arrow). brown (globule-like) areas in the central part (white arrow).
(black arrow) and central white patch (red arrow). Round grayish or (black arrow) and central white patch (red arrow).
brown (globule-like) areas in the central part (white arrow).
Delicate peripheral pigment network: It is not a true •• Presence of linear vessels, occasionally with reticular
pigment network since it is due to melanic rather than appearance (Figs. 5.148 to 5.150)
melanocytic pigmentation. •• Blue or red areas (hemosiderotic dermatofibroma)
Central white pach or area: It has a scar-like appear- (Fig. 5.151)
ance and is due to the superficial dermic fibrosis of this •• Absence of white patch in highly pigmented lesions
tumor. (Figs. 5.152 to 5.155)
It is usually in this central zone where the most dermo- White shiny linear streaks or crystal structures (Figs.
scopic variations are observed: 5.156 to 5.160):
•• Central white patches covering an important area of •• White shiny linear streaks not visible to the naked eye
the lesion (Figs. 5.144 to 5.146) or with the dermoscope with nonpolarized light. They
•• Round grayish or brown (globule-like) areas in the are visible in lesions with an increased amount of colla-
central part (Figs. 5.137 to 142, 144, and 5.147) gen (melanoma, dermatofibroma, scars, and basal cell
Fig. 5.144: Dermatofibroma: central white patches covering an impor Fig. 5.145: Dermatofibroma: central white patches covering an impor
tant area of the lesion (red arrow). Round grayish or brown areas in the tant area of the lesion (arrow).
central part (globule-like) (white arrow).
Fig. 5.146: Dermatofibroma: central white patches covering an impor Fig. 5.147: Dermatofibroma: round grayish or brown areas in the
tant area of the lesion (arrow). central part (globule-like) (white arrow). Delicate peripheral pigment
network (black arrow).
Fig. 5.148: Dermatofibroma: presence of linear vessels, occasionally Fig. 5.149: Dermatofibroma: presence of linear vessels, occasionally
with reticular appearance (arrow). with reticular appearance (arrow).
Fig. 5.150: Dermatofibroma: presence of linear vessels, occasionally Fig. 5.151: Dermatofibroma: blue or red areas (hemosiderotic derma-
with reticular appearance (arrow). tofibroma) (arrow).
Fig. 5.152: Dermatofibroma. Absence or irregular distribution of white Fig. 5.153: Dermatofibroma: absence or irregular distribution of white
patch in highly pigmented lesions patch in highly pigmented lesions.
Fig. 5.154: Dermatofibroma: absence or irregular distribution of white Fig. 5.155: Dermatofibroma: absence or irregular distribution of white
patch in highly pigmented lesions. patch in highly pigmented lesions.
Fig. 5.156: White shiny linear streaks or crystal structures (arrow). Fig. 5.157: White shiny linear streaks or crystal structures (arrow).
Fig. 5.158: White shiny linear streaks or crystal structures. Fig. 5.159: White shiny linear streaks or crystal structures (arrow).
Fig. 5.160: White shiny linear streaks or crystal structures (arrow).

carcinoma). The collagen fasciae are birefringent and Arpaia N, Cassano N, Vena GA. Dermoscopic patterns of derma-
these give rise to a rapid randomization of the polarized tofibroma. Dermatol Surg. 2005;31:1336-9.
light.
•• It is a dynamic polarized dermoscopy since by rotating Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment
the dermoscope while keeping it in contact with the Guide, 2nd edition. New York: McGraw-Hill Education; 2015.
cutaneous surface, the orientation of the crystalline Ferrari A, Soyer HP, Peris K, et al. Central white scarlike patch:
structures changes. This is owing to the angular dep a dermoscopic clue for the diagnosis of dermatofibroma.
endence of the polarized light, reflecting the non-ran- J Am Acad Dermatol. 2000;43:1123-5.
Kilinc Karaarslan I, Gencoglan G, Akalin T, et al. Different der-
domized distribution of the collagen fibers in the
moscopic faces of dermatofibromas. J Am Acad Dermatol.
dermis. 2007;57:401-6.
Zaballos P, Guionnet N, Puig S, et al. Central white network: an
SUGGESTED READING additional dermoscopic feature for the diagnosis of dermato-
fibroma. Dermatol Surg. 2005;31:960-2.
Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of pig- Zaballos P, Llambrich A, Ara M, et al. Dermoscopic findings of
mented skin lesions: results of a consensus meeting via the haemosiderotic and aneurysmal dermatofibroma: report of
internet. J Am Acad Dermatol. 2003;48:679-93. six patients. Br J Dermatol. 2006;154:244-50.
Argenziano G, Zalaudek I, Corona R, et al. Vascular struc- Zaballos P, Puig S, Llambrich A, et al. Dermoscopy of dermatofi-
tures in skin tumors: a dermoscopy study. Arch Dermatol. bromas: a prospective morphological study of 412 cases. Arch
2004;140:1485-9. Dermatol. 2008;144:75-83.
5.6 ACTINIC KERATOSES

Actinic or solar keratoses (AKs) are the most frequent Clinical diagnosis is made on pink-colored lesions
among solar-exposure-related cutaneous tumors. with scaly surface. Actinic keratosis may become pigmen
They are considered premalignant lesions, since bet ted as well.
ween 10 and 20% of them may evolve into a squamous cell The main differential diagnoses are as follows (Figs.
carcinoma (SCC). Bowen’s disease is considered an SCC 5.161 to 5.164):
in situ. •• Nonpigmented forms: Nonpigmented superficial basal
These lesions are more frequent in fair-skinned, light- cell carcinoma and early or flat seborrheic keratosis
eyed, and blond-haired people. (solar lentigo)
Nevertheless, they can manifest in any kind of skin, •• Pigmented forms: Lentigo maligna (LM) and solar lentigo
depending on the level of solar exposure. The most affected In all hyperkeratotic AK with increased erythema and
areas are the exposed ones. induration, we should perform a biopsy to discard SCC.
Fig. 5.161: Superficial basal cell carcinoma. Pink lesion with differential Fig. 5.162: Superficial basal cell carcinoma. Pink lesion with differential
diagnosis of actinic keratosis. diagnosis of actinic keratosis.
Fig. 5.163: Solar lentigo. Differential diagnosis of pigmented actinic Fig. 5.164: Solar lentigo. Differential diagnosis of pigmented actinic
keratosis. keratosis.
DERMOSCOPIC CRITERIA four-leafed clover, located mainly within the follicular

opening. They are nonspecific, and observable also in
Nonpigmented Actinic Keratosis other tumors, specially keratinizing ones (Figs. 5.171
to 5.174).
•• Strawberry-like pattern: It is possible to observe white
or white-yellow follicular openings in a reddish back- Pigmented Actinic Keratosis (Fig. 5.175)
ground with the appearance of the surface of a straw- They may be very difficult to distinguish from LM since
berry (Figs. 5.165 to 5.168). they present almost the same criteria, except for the homo-
•• Vascular pattern with fine undulated vessels sur- geneous blue-gray areas, which may spread or not into the
rounding the hair follicle, dot-like vessels, and spi- follicular openings (Figs. 5.168, 5.174, 5.176 to 5.178).
ral-like vessels (Figs. 5.168 to 5.170). •• Superficial brown color with the appearance of broken
•• Superficial yellowish-white scales (Figs. 5.167 and 5.171) pseudonetwork
•• Hyperkeratotic follicles (Fig. 5.168) •• Hyperkeratotic follicles
•• Rosettes: They are observable with polarized light and •• Inner gray halo: Subtle homogeneous gray or light
correspond to four grouped white dots, resembling a brown halo surrounding the follicular openings in
Fig. 5.165: Actinic keratosis: strawberry pattern (red circles). Fig. 5.166: Actinic keratosis: strawberry pattern (red circle). Rosette-
like structures (black arrow).
Fig. 5.167: Actinic keratosis: strawberry pattern (red circle). Fig. 5.168: Undulated vessels surrounding the hair follicle (white circle).
Fig. 5.169: Actinic keratosis: dot-like vessels. Fig. 5.170: Actinic keratosis: strawberry pattern (white arrow); white-
to-yellow surface scale (red circles).
Fig. 5.171: Actinic keratosis: rosette-like structures (green circles). Fig. 5.172: Actinic keratosis: rosette-like structures (white arrows);
white-to-yellow surface scale and small erosion (red arrows).
Fig. 5.173: Pigmented (black circle) and nonpigmented (red circle) Fig. 5.174: Pigmented actinic keratosis: pigmentation of the follicular
actinic keratosis in the same lesion. openings (red circle); rosette-like structures (black arrow).
Fig. 5.175: Actinic keratosis: pigmentation of the follicular openings (red Fig. 5.176: Pigmented actinic keratosis; annular–granular pattern with
arrow); strawberry pattern (black arrow); undulated vessels surrounding symmetric and asymmetric slate-gray pigmentation of the follicular
the hair follicle (white arrows); and hyperkeratotic follicles (blue arrow). openings (red circle).
A B
C D
Figs. 5.177A to D: Pigmented actinic keratosis; clinical and dermoscopy images.
Cuellar F, Vilalta A, Puig S, et al. New dermoscopic pattern in

actinic keratosis and related conditions. Arch Dermatol.
2009;145:732.
(MOABT). New York: Elsevier Ltd.; 2004.
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at.
Lallas A. Dermoscopy in general dermatology, Dermatol Clin.
2013;3:679-94.
Lallas A, Argenziano G, Moscarella E, et al. Diagnosis and man-
agement of facial pigmented macules. Clin Dermatol. 2014;
32:94-100.
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-
Fig. 5.178: Pigmented actinic keratosis (closeup view of Figures ciones Gráficas; 2009.
5.177C): slate gray to black dots and slate gray to black globules as Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
part of an annular–granular pattern (red circle). Rhomboidal structures Taylor & Francis; 2005.
(white arrows). Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros-
copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
Company; 1996.
Nascimento M, Shitara D, Enokihara M, et al. Inner gray halo,
the manner of an inner ring within the mesh of the a novel dermoscopic feature for the diagnosis of pigmented
brown pseudonetwork. It is the result of the pigmen- actinic keratosis: Clues for the differential diagnosis with len-
tation of the basal keranocytes surrounding the hair tigo maligna. J Am Acad Dermatol. 2014;71:708-15.
follicle. Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
•• Asymmetric pigmentation of the follicular opening Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig-
(which can also be found in LM) mented Skin Lesions. An Atlas Based on the Consensus Net
•• Rhomboidal structures (also found in LM) Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Histopathological examination can be difficult, since New Media; 2001.
Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos-
on occasion it is hard to differentiate pigmented kerano- copy. Germany: Blackwell Science; 1994.
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Acad Dermatol Venereol. 2015:29:120-7.
Zalaudek I. Morphologic grading and treatment of facial actinic
SUGGESTED READING keratosis. Clin Dermatol. 2014;32(1):80-7.
Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
of Dermoscopy. Milán: EDRA Medical Publishing & New Zalaudek I, Ferrara G, Leinweber B, et al. Pitfalls in the clinical
Media; 2000. and dermoscopic diagnosis of pigmented actinic keratosis.
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; J Am Acad Dermatol. 2005;53:1071-4.
2000. Zalaudek I, Giacomel J, Argenziano G, et al. Dermatoscopy of
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: facial non-pigmented actinic keratosis. Br J Dermatol. 2006;
Ediciones Journal; 2012. 155:951-6.
5.7 KERATOACANTHOMA, BOWEN’S DISEASE AND SQUAMOUS CELL CARCINOMA

KERATOACANTHOMA presence of these dermoscopic characteristics makes it

feasible to differentiate KA and SCC from other nonpig-
Keratoacanthoma (KA) is a keratinizing tumor presenting mented tumorous lesions.
a central crater or hyperkeratosis (Fig. 5.179). Central hyperkeratosis is more frequent in KA than in
Dermoscopically, it is characterized by the presence of SCC. The blood spots are distributed in the keratin. The
mainly thick hairpin vessels with peripheral distribution white circles are located around the dilated infundibulum
and central hyperkeratosis. It is also frequent to observe filled with a central keratin plug (yellowish keratotic plug)
irregular linear vessels (Fig. 5.180). and observable as a yellow or an orange area (clods); these
It is worth mentioning that both in KA and in squa- structures do not correspond to keratin pearls. Histo
mous cell carcinoma (SCC), it is possible to find keratin pathologically, they present acantholysis and epidermal
structures, blood spots, and white areas and circles. The infundibular hypergranulosis (Figs. 5.181 to 5.184).
Fig. 5.179: Keratoacanthoma. Fig. 5.180: Keratoacanthoma: central hyperkeratosis (black arrow);
peripheral vessels (red arrow).
Fig. 5.181: Keratoacanthoma: central hyperkeratosis (white arrow); Fig. 5.182: Keratoacanthoma: central hyperkeratosis (black arrow);
blood spots in the central crater or hyperkeratosis (black arrows); white white circles or areas (red arrow).
circles or areas (red arrows).
Fig. 5.183: Keratoacanthoma: central hyperkeratosis (black arrow); Fig. 5.184: Keratoacanthoma: central hyperkeratosis (black arrow);
peripheral hairpin vessels (red arrows); white, yellow, or orange areas peripheral hairpin vessels (red arrows); white, yellow, or orange areas
(white arrows). or circles (white arrows).
Fig. 5.185: Squamous cell carcinoma in situ—nonpigmented Bowen’s Fig. 5.186: Squamous cell carcinoma in situ—nonpigmented Bowen’s
disease: glomerular or spiral vessels, monomorphic pattern, focal disease: glomerular or spiral vessels, monomorphic pattern, focal
distribution (arrow). distribution (red arrow) (clinical view black arrow).
Dermoscopic Criteria In most cases, its clinical manifestation is a well-

•• Central hyperkeratosis demarcated pink and scaly (squamous) plaque. Differen-
•• Vessels tial diagnosis includes actinic keratosis, eczema, psoria-
–– Thick hairpin vessels with peripheral distribution sis, seborrheic dermatitis, Paget’s disease, and superficial
–– Linear irregular vessels basal cell carcinoma.
•• Blood spots The dermoscopic key in nonpigmented BD is the
•• White areas and circles monomorphic vascular pattern with focal distribution,
whose morphology is spiral or glomerular (tight spiral ves-
Bowen’s Disease sels, which may resemble areas or globules at small mag-
Squamous Cell Carcinoma In Situ—Nonpigmented nification) (Figs. 5.185 to 5.196).
Bowen’s Disease
Dermoscopy is useful in the diagnosis of SCC in situ or
Dermoscopic Criteria
Bowen’s disease (BD). The most frequent variant is the •• Vessels
nonpigmented form. –– Glomerular or spiral vessels
disease: glomerular or spiral vessels, monomorphic pattern, focal dis- disease: glomerular or spiral vessels, monomorphic pattern, focal
tribution (arrow). distribution (arrow).
disease: glomerular or spiral vessels, monomorphic pattern, focal dis- disease: glomerular or spiral vessels, monomorphic pattern, focal dis-
tribution (arrow). tribution (arrow).
disease: (close up of Fig. 5.190) glomerular or spiral vessels, mono disease: glomerular or spiral vessels, monomorphic pattern, focal
morphic pattern, focal distribution (arrow). distribution (arrow).
Fig. 5.193: Squamous cell carcinoma in situ—nonpigmented Bowen’s Fig. 5.194: Squamous cell carcinoma in situ–nonpigmented Bowen’s
disease: glomerular or spiral vessels, monomorphic pattern, focal dis- disease: glomerular or spiral vessels, monomorphic pattern, focal dis-
tribution (arrow). tribution (arrow).
disease: (close up Fig. 5.194) glomerular or spiral vessels, monomor- disease: glomerular or spiral vessels, monomorphic pattern, focal
phic pattern, focal distribution (arrow). distribution (arrows marking left and right side of the lesion).
–– Monomorphic pattern
–– Focal distribution
•• Rough surface
Squamous Cell Carcinoma In Situ—Pigmented

Bowen’s Disease
Pigmented Bowen’s disease (PBD) is a rare variant of BD
(Fig. 5.197).
Its clinical manifestation is a well-demarcated pink
or brownish macula or squamous plaque. The differen-
tial diagnosis includes pigmented actinic keratosis, solar
lentigo, seborrheic keratosis, lichen planus-like keratosis,
pigmented basal cell carcinoma, nevi, and melanomas.
Fig. 5.197: Squamous cell carcinoma. (Pigmented Bowen’s disease) Pigmented Brown’s disease presents a characteristic
clinical view.
dermoscopic pattern, prominently a pattern of structureless
Fig. 5.198: Squamous cell carcinoma in situ—pigmented Bowen’s dis- Fig. 5.199: Squamous cell carcinoma in situ—pigmented Bowen’s dis-
ease: brown color (brown arrow); structureless areas (hypopigmented: ease: brown color (brown arrow); structureless areas (hypopigmented:
pink, skin colored, or white) (white arrow); linear arrangement of pink, skin colored, or white) (white arrow); linear arrangement of
brown or gray dots (black arrow); coiled vessels: arranged in linear brown or gray dots (black arrow); coiled vessels: arranged in linear
fashion or in clusters (red arrow). fashion or in clusters (red arrow).
Fig. 5.200: Squamous cell carcinoma in situ—pigmented Bowen’s Fig. 5.201: Squamous cell carcinoma in situ—pigmented Bowen’s dis-
disease: brown color (brown arrow); structureless areas (hypopigmen ease: brown color (brown arrow); structureless areas (hypopigmented:
ted: pink, skin colored, or white) (white arrow); coiled vessels: arranged pink, skin colored, or white) (white arrow); linear arrangement of
in linear fashion or in clusters (red arrows). brown or gray dots (black arrow).
areas, as well as a combination of brown or gray dots. The •• Brown color

most common color in these lesions is brown in its chro- •• Structureless areas
matic variants. The vessels, spiral or loop-like, are arranged •• Hypopigmented—pink skin colored, or white.
in linear fashion in the periphery of the lesion or in clusters –– Vessels
or groups. On occasion, PBD may not present any of these •• Spiral or loop-like vessels
•• Linear arrangement
dermoscopic clues (Figs. 5.198 to 5.206).
•• In clusters or groups
Dermoscopic Criteria –– Without dermoscopic clues
Linear arrangement of brown or gray dots Squamous Cell Carcinoma

This feature lies most frequently in the periphery of the In its progression, infiltrating SCC invades the underlying
lesion with the lines radially arranged. tissue. The typical lesion is a firm and pink raised plaque
Fig. 5.202: Squamous cell carcinoma in situ—pigmented Bowen’s Fig. 5.203: Squamous cell carcinoma in situ—pigmented Bowen’s
disease: brown color (brown arrow); structureless areas (hypopigment- disease: brown color (brown arrow); structureless areas (hypopigmen
ed: pink, skin colored, or white) (white arrow); coiled vessels: arranged ted: pink, skin colored, or white) (white arrow); linear arrangement of
clusters (red arrow). brown or gray dots (black arrow); coiled vessels: arranged in linear
fashion or in clusters (red arrows).
Fig. 5.204: Squamous cell carcinoma in situ—pigmented Bowen’s dis- Fig. 5.205: Squamous cell carcinoma in situ—pigmented Bowen’s dis-
ease: brown color (brown arrow); structureless areas (hypopigmented: ease: brown color (brown arrow); structureless areas (hypopigmented:
pink, skin colored, or white) (white arrow). pink, skin colored, or white) (white arrow).
or tumor on photodamaged skin. The surface may be arranged in the periphery of the lesion; it may be associ-
covered in crusts or ulcerated. Differential diagnosis must ated with variable ulceration areas and scales (Figs. 5.208
be made, especially, with KA, ulcerated BCC, and amela- to 5.211).
notic melanoma (Fig. 5.207).
Dermoscopically, it is possible to observe, in the cen- Dermoscopic Criteria
ter of the lesion, areas without structure, white, yellow, or •• Hyperkeratosis usually located in the central part of
light brown in color, and amorphous areas corresponding the lesion
to hyperkeratosis usually located in the central part; also •• Blood spots in the hyperkeratosis areas
blood spots distributed in the keratin and white circles •• White, yellow, or light brown structureless areas
surrounding the dilated infundibulum filled with a central •• White circles
keratin plug resembling yellow or orange clods. The ves- •• Vessels: glomerular, hairpin, or irregular linear vessels
sels can be glomerular, although these tumors typically •• Ulceration
present mostly hairpin vessels or irregular linear vessels, •• Scales
Fig. 5.206: Squamous cell carcinoma in situ—pigmented Bowen’s dise Fig. 5.207: Squamous cell carcinoma (Clinical view).
ase: brown color (brown arrow); structureless areas (hypopigmented:
pink, skin colored, or white) (white arrow); coiled vessels: arranged in clus-
ters (red arrow).
Fig. 5.208: Squamous cell carcinoma: hyperkeratosis (white arrow); blood Fig. 5.209: Squamous cell carcinoma: hyperkeratosis (white arrow);
spots and ulceration (red arrow); white structureless areas (black arrow); blood spots and ulceration (red arrow); white structureless areas (black
white circles (blue arrows); glomerular, hairpin, or irregular linear vessels. arrow); white circles (blue arrow).
Fig. 5.210: Squamous cell carcinoma: blood spots and ulceration Fig. 5.211: Squamous cell carcinoma: blood spots and ulceration
(red arrow); white structureless areas (black arrow); hairpin and linear (red arrow); white structureless areas (black arrow); white circles (blue
irregular vessels (white arrow). arrow); hairpin and linear irregular vessels (white arrow).
SUGGESTED READING Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros-

Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Company; 1996.
of Dermoscopy. Milán: EDRA Medical Publishing & New Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
Media; 2000. American Academy of Dermatology; 1999.
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro;
Rosendahl C, Cameron A, Argenziano G, et al. Dermoscopy of
2000.
squamous cell carcinoma and keratoacanthoma. Arch Der-
Ediciones Journal; 2012. matol. 2012;148(12):1386-92.
Cameron A, Rosendahl C, Tschandl P, et al. Dermatoscopy of Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig-
pigmented Bowen’s disease. J Am Acad Dermatol. 2010;62: mented Skin Lesions. An Atlas Based on the Consensus Net
597-604. Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
(MOABT). New York: Elsevier Ltd.; 2004. Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos-
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment copy. Germany: Blackwell Science; 1994.
Guide, 2nd edition. New York: McGraw-Hill Education; 2015. Vazquez-Lopez F, Manjon-Haces JA, Maldonado-Seral C, et al.
Kim C, Ko CJ, Leffell DJ. Cutaneous squamous cell carcinomas of Dermoscopy of Bowen’s disease. Br J Dermatol. 2004; 150:
the lower extremity: a distinct subset of squamous cell carci- 1112-6.
nomas. J Am Acad Dermatol. 2014;70:70-4. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
tern Analysis 2011 Facultas Verlags- und Buchhandels AG Zalaudek I, Citarella L, Soyer HP, et al., Dermoscopy features of
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at.
pigmented squamous cell carcinoma: a case report. Derma-
tol Surg. 2004;30:539-40.
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Zalaudek I, Di Stefani A, Argenziano G. The specific dermoscopic
Lin MJ, Pan Y, Jalilian C, et al. Dermoscopic characteristics of
nodular squamous cell carcinoma and keratoacanthoma. criteria of Bowen’s disease. J Eur Acad Dermatol Venereol.
Dermatol Pract Concept. 2014;4(2):9-15. 2006;20:361-2.
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea- Zalaudek I, Giacomel J, Schmid K, et al. Dermatoscopy of actinic
ciones Gráficas; 2009. keratosis, intraepidermal carcinoma and invasive squamous
Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London: cell carcinoma: a progression model. J Am Acad Dermatol.
Taylor & Francis; 2005. 2012;66(4):589-97.
5.8 OTHER NONMELANOCYTIC LESIONS

5.8.1 Eccrine Poroma
Eccrine poroma (EP) is a benign adnexal tumor derived Eccrine poroma has two variants: Pigmented (less fre-
from the acrosyringium and the intraepidermal part of the quent) and nonpigmented. Dermoscopy has proved to be
eccrine sweat glands excretory duct. Clinically, it appears especially useful since it enables the evaluation of vascular
structures showing a polymorphic vascular pattern, with
as a solitary pink nodule, generally located at acral level
hairpin vessels, dotted vessels, irregular linear vessels, and
(palms and soles) in adults. Differential diagnosis must
pink lacunae surrounded by a whitish halo looking like
be performed with benign tumorous lesions (mainly pyo- “frog eggs.” There have also been descriptions of arboriz-
genic granuloma and seborrheic keratosis) and malignant ing vessels, typically with a flower-like or grail-like appear-
lesions [basal cell carcinoma (BCC) and melanoma]. ance (Figs. 5.212 to 5.218).
Fig. 5.212: Eccrine poroma (nonpigmented form). Fig. 5.213: Eccrine poroma: flower-like appearance (black arrows);
frog eggs like appearance (white circle).
Fig. 5.214: Eccrine poroma (nonpigmented form). Fig. 5.215: Eccrine poroma: different views of the same lesion showing
the typical frog eggs’ aggregation.
Fig. 5.216: Eccrine poroma: frog eggs like appearance (white circle). Fig. 5.217: Eccrine poroma (nonpigmented form).
Fig. 5.218: Eccrine poroma: flower-like appearance (black arrows); Fig. 5.219: Eccrine poroma (pigmented form).
frog eggs like appearance (white circle).
Fig. 5.220: Eccrine poroma (pigmented form): round light-brown Fig. 5.221: Eccrine poroma (pigmented form).
areas divided by a darker colored partition. Pseudo-red appearance.
Fig. 5.222: Eccrine poroma (pigmented form): round light-brown Fig. 5.223: Eccrine poroma (pigmented form).
areas or nests divided by darker brown partitions. Pseudo-network
image (white circle); flower-like appearance (black arrow).
Fig. 5.224: Eccrine poroma (pigmented form): round blue–gray areas or

nests (white circle); flower-like appearance (black arrow).
Besides the vascular structures, the pigmented variant SUGGESTED READING

presents nests and brown or blue-gray dots; as a result,
Ferrari A, Buccini P, Silipo V, et al. Eccrine poroma: a clini-
it must be differentiated from pigmented BCC. However, cal-dermoscopic study of seven cases. Acta Derm Venereol.
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to 5.224). Minagawa A, Koga H. Dermatology. Dermoscopy of pigmented
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Minagawa A, Koga H, Takahashi M, et al. Dermoscopic features
of nonpigmented eccrine poromas in association with their
histopathological features. Br J Dermatol. 2010;163:1264-8.
5.8.2 Clear Cell Acanthoma

Clear cell acanthoma is a rare benign tumor that appears like a “string of pearls.” Although dotted vessels are typical
as a pink papuloid lesion localized in the lower limb of of melanocytic tumors, they are evenly distributed over the
adults. whole lesion. On the other hand, in clear cell acanthoma
Under dermoscopic examination, it is possible to obs the dotted vessels are surrounded by a whitish halo, typi-
erve dotted or globular vessels with linear arrangement, cal of keratinizing tumors (Figs. 5.225 to 5.227).
Fig. 5.225: Clear cell acanthoma: dotted or globular vessels in linear Fig. 5.226: Clear cell acanthoma: dotted or globular vessels in linear
arrangement, like a “string of pearls” (arrow). arrangement, like a “string of pearls” (arrow).
Fig. 5.227: Clear cell acanthoma: dotted or globular vessels in linear

arrangement, like a “string of pearls” (arrow).
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Blum A, Metzler G, Bauer J, et al. The dermoscopic pattern of Guide, 2nd edition. New York: McGraw-Hill Education; 2015.
clear-cell acanthoma resembles psoriasis vulgaris. Dermatol- Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-
ogy. 2001;203:50-2. ciones Gráficas; 2009.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
Ediciones Journal; 2012. Taylor & Francis; 2005.
5.8.3 Cylindroma
Cylindromas are benign tumors derived from the apocrine In dermoscopy, it is possible to observe pink areas,
glands. They appear as dome-shaped erythematous nod- arborizing vessels, blue dots or globules, and ulceration,
ules, solitary or multiple, and generally localized in the all of which make the cylindroma a basal cell carcinoma
head and neck, although they can also appear in the upper simulator, as both tumors share the same dermoscopic
trunk. criteria (Fig. 5.228).
Fig. 5.228: Cylindroma: arborizing vessels (red arrow) and ulceration (black
arrow).
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matol Pract Concept. 2013;4(1):10.
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Dermatol Res Pract. 2010;2010:285392. droma. Eur J Dermatol. 2011;21(4):645-6.
5.8.4 Trichoepithelioma
Trichoepithelioma (TE) is a benign adnexal tumor derived In dermoscopy, solitary tumors present arborizing
from the germinal matrix of the hair follicle. Most fre- telangiectasia and white shiny or crystalline structures,
quently, there is a solitary lesion, although there are also similar to BCC. However, TE usually lacks the other der-
multiple forms, and a desmoplastic TE variant. Clinically, moscopic criteria of BCC, namely blue–gray globules and
it appears as a pink papule or nodule, usually occurring on nests, and maple-leaf structures (Fig. 5.229).
the face in young individuals. Its main differential diagno-
sis is basal cell carcinoma (BCC).
Fig. 5.229: Trichoepithelioma with arborizing vessels (red arrow); white shiny
or crystalline structures (black arrow).
SUGGESTED READING
Lazaridou E, Fotiadou C, Patsatsi A, et al. Solitary trichoepithe-
lioma in an 8-year-old child: clinical, dermoscopic and his-
topathologic findings. Dermatol Pract Concept. 2014; 4(2):
55-8.
5.8.5 Verrucae Vulgaris

Verrucae vulgaris (VV) are caused by some types of human •• Dotted vessels or homogeneous red-black globules
papilloma virus. They appear as hyperkeratotic papules, corresponding, respectively, to dilated or thrombosed
scaly, and rough, solitary or multiple. They are more fre- vessels. These structures may be surrounded by a
quent in children and young adults, occurring in hands, white halo that betrays the presence of papillomatosis.
feet, and limbs. •• Exceptionally, it is possible to observe polymorphous
Dermoscopically, VV is characterized by the following vessels (hairpin, dotted, spiral, or irregular linear ves-
(Figs. 5.230 to 5.232): sels) and ulceration areas.
Fig. 5.230: Verrucae vulgaris: thrombotic or dilated vessels (red arrow) Fig. 5.231: Verrucae vulgaris: thrombotic or dilated vessels (red
in multiple round or oval areas (black arrow). arrow) in multiple round or oval areas (black arrow) (closeup view of
Figure 5.230).
Fig. 5.232: Verrucae vulgaris: thrombotic or dilated vessels (red arrow) in

multiple round or oval areas (black arrow).

5.8.6 Molluscum Contagiosum

Disease is occurring worldwide. Its etiologic agent is the •• Orifice: The growth of viral matter may cause a break
molluscum contagiosum (MC) virus, which belongs to in the skin.
the poxvirus family. It is more frequent in children, but •• Peripheral hairpin vessels in “red crown” arrangement
can also appear in adults, in which case it is considered a not crossing the central lobules
sexually transmitted infection. Clinically, it appears as •• Linear (radial) vessels arranged perpendicularly with-
round dome-shaped papules, umbilicated, translucent and out crossing the central pore
firm, 2–5 mm, pink, pearly white, or skin colored (Fig. 5.233). •• Dotted vessels
Dermoscopically, MC presents the following patterns Most frequently, the central pore has radial and
(Fig. 5.234): crown vessels. When these vessels surround the lesion
•• “Fried egg” pattern, due to the presence of round completely, the lesion is called “mixed flower-like pat-
structures with a central pore tern.” This recently described pattern appears to be MC
•• Polylobular amorphous white–yellow structure specific.
Fig. 5.233: Molluscum contagiosum. Fig. 5.234: Molluscum contagiosum: polylobular amorphous white–
yellow structure (red arrow); peripheral hairpin vessels in “red crown”
arrangement (white arrow); linear (radial) vessels arranged perpendi
cularly without crossing the central pore (black arrow).

Zaballos P, Ara M, Puig S, et al. Dermoscopy of molluscum conta-
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea- giosum: a useful tool for clinical diagnosis in adulthood. J Eur
ciones Gráficas; 2009. Acad Dermatol Venereol. 2006;20:482-3.
5.8.7 Sebaceous Hyperplasia

Sebaceous hyperplasia (SH) is a common benign tumoral •• Structureless white-yellowish aggregated areas
lesion occurring on the face of adult patients. From a clini •• Central umbilication, corresponding to the hyperpla-
cal point of view, it presents as a white-yellowish papule, sic sebaceous gland duct
sometimes umbilicated, of <1 cm. Among its differential •• Curved linear vessels with peripheral radial or crown
diagnoses, we find molluscum contagiosum, basal cell arrangement, surrounding the center of the lesion but
carcinoma, milia-like cysts, and fibrous papula (Figs. without crossing it
5.235 and 5.236). The sign, known as “toffee chocolate sign,” has been
Dermoscopically, SH presents the following patterns described, corresponding to a central depression sur-
(Figs. 5.237 to 5.239): rounded by white-yellowish aggregated globules. This
Fig. 5.235: Sebaceous hyperplasia: clinical image. Fig. 5.236: Sebaceous hyperplasia: clinical image.
Fig. 5.237: Sebaceous hyperplasia: structureless white-yellowish aggre- Fig. 5.238: Sebaceous hyperplasia: structureless white-yellowish aggre-
gated areas (red arrow); central umbilication (black arrow); curved linear gated areas (red arrow); central umbilication (black arrow); curved linear
vessels with peripheral radial or crown arrangement (white arrow). vessels with peripheral radial or crown arrangement (white arrow).
Fig. 5.239: Sebaceous hyperplasia: structureless white-yellowish aggre-

gated areas (red arrow); central umbilication (black arrow); curved linear
vessels with peripheral radial or crown arrangement (white arrow).
umbilication would correspond to the visible presence of Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-
the gland ostium. ciones Gráficas; 2009.
SUGGESTED READING Taylor & Francis; 2005.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Zaballos P, Ara M, Puig S, et al. Dermoscopy of sebaceous hyper-
Ediciones Journal; 2012. plasia. Arch Dermatol. 2005;141:808.
5.8.8 Porokeratosis
Porokeratosis (PK) comprises a group of skin diseases due apparently corresponds to the cornoid lamella (Fig.
to a hereditary keratinization alteration. It has different 5.241).
clinical manifestations sharing the same histopathologic •• The central area may have brown pigmentation, which
pattern: a cornoid lamella (Fig. 5.240). probably represents the longitudinal ridge of the lesion;
Dermoscopically, PK features as follows: there may also be dots, globules, and red lines due to
•• A well-demarcated annular gray or whitish periph- dilated capillaries present underneath an atrophic epi-
eral border, known as “white tract.” Sometimes the dermis, or a scar-like zone with scales (a scale scar-like
classical double “rail band” is present. This structure zone) (Fig. 5.242).
Fig. 5.240: Porokeratosis. Fig. 5.241: Porokeratosis: classical double “rail band” (arrow).
Fig. 5.242: Porokeratosis: classical double “rail band” (red arrow); dots,
globules, and red lines due to dilated capillaries (white arrow); scar-like
depigmentation (black arrow).
SUGGESTED READING
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea- Zaballos P, Puig S, Malvehy J. Dermoscopy of disseminated super-
ciones Gráficas; 2009. ficial actinic porokeratosis. Arch Dermatol. 2004;140:1410.
5.8.9 Pyogenic Granuloma

Horacio A Cabo
Dermoscopically, pyogenic granuloma features reddish and white rail lines crossing the lesion. Occasionally, there
homogeneous or whitish-red areas, with white collarete may be a hemorrhagic crust (Figs. 5.243 and 5.244).
Fig. 5.243: Pyogenic granuloma (clinical image). Fig. 5.244: Pyogenic granuloma: reddish homogeneous or whitish-
red areas (white arrow); white collarette (red arrow); white rail lines
crossing the lesion (black arrow).
SUGGESTED READING
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea- Zaballos P, Llambrich A, Cuellar F, et al. Dermoscopic findings in
ciones Gráficas; 2009. pyogenic granuloma. Br J Dermatol. 2006;154:1108-11.
5.8.10 Lichen Planus

Lichen planus (LP) may affect skin, mucosa, and hair (Fig. Dermoscopic findings consist in pearly white poly-
5.245). morphous structures corresponding to WS with arborizing
The classic cutaneous lesion is a flat polygonal papule projections, “fern-leaf-like” appearance. In the borders,
slightly erythematous or purplish, in whose upper part it is there may appear linear vessels (capillary vessels) and
possible to observe reticular or whitish dotted formations. erythematous globules. The presence of WS in the dermo-
The surface presents reticular or white dot-like formations, scopic analysis is the diagnosis key to differentiate LP from
known as Wickham streaks (WSs), which characterize this other disorders like pityriasis rosea and psoriasis (Fig.
disease. 5.246).
Fig. 5.245: Lichen planus clinical image. Fig. 5.246: Lichen planus: fern-leaf-like appearance (red arrow); linear
vessels (black arrow).
SUGGESTED READING
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-
Ediciones Journal; 2012. ciones Gráficas; 2009.
Friedman P, Cohen Sabban E, Marcucci C, et al. Dermoscopic Marghoob AA. Dermoscopic features of plaque psoriasis and lichen
findings in different clinical variants of lichen planus. Is der-
moscopy useful? Dermatol Pract Concept. 2015;5(4):51-5. planus: new observations. Dermatology. 2003;207:151-6.
5.8.11 Bowenoid Papulosis

Bowenoid papulosis is a multifocal intraepithelial neo- •• Dotted vessels or homogeneous red–black globules
plasm occurring in the anogenital region. The main dif- corresponding respectively to dilated or thrombosed
ferential diagnosis, both clinical and dermoscopic, is the vessels. These structures may be surrounded by a
verruca genitalis (Figs. 5.247A and B). white halo that betrays the presence of papilomatosis.
The characteristic features of this lesion are as follows •• Gray–brown dots, in linear arrangement, located in
(Figs. 5.248 to 5.250): the periphery of the lesion.
A B
Figs. 5.247A and B: Bowenoid papulosis: clinical images (A and B). Fig. 5.248: Bowenoid papulosis: (case A) red or blue dilated vessels
(red arrow) in multiple round or oval areas (black arrow). These
structures are surrounded by a white halo which betrays the presence
of papillomatosis (white arrow).
Fig. 5.249: Bowenoid papulosis: (case A) gray–brown dots, in linear Fig. 5.250: Bowenoid papulosis: (case B) gray–brown dots, in linear
arrangement, in the periphery of the lesion (arrows). arrangement, in the periphery of the lesion (arrows).
SUGGESTED READING
Marcucci C, Cohen Sabban E, Friedman P, et al. Dermoscopic
findings in bowenoid papulosis: report of two cases. Derma-
tol Pract Concept. 2014;4(4):61-3.
MELANOCYTIC LESIONS 6
Horacio A Cabo
“The dermoscopic study of pigmented lesions is performed in two steps. The first step involves determining
if the lesion is melanocytic or nonmelanocytic. If it is a melanocytic lesion, the physician must continue with
the second step, which means differentiating a benign melanocytic lesion from a melanoma.
In this chapter, we include concepts of Nevogenesis, the different types of nevus, such as congenital,
acquired, atypical, blue nevus, combined and recurrent nevus.
The different types of melanoma, superficial spreading melanoma, nodular melanoma,
lentigo maligna melanoma and acral melanoma will be included as well.
Finally, we will focusing in the approach of patients with multiple nevi.”
Melanocytic Lesions 113
6.1 CRITERIA OF MELANOCYTIC LESIONS

Horacio A Cabo
The dermoscopic study of pigmented lesions is performed Aggregated Globules

in two steps. The first step involves determining if the Multiple oval or round structures, well demarcated; of diff
lesion is melanocytic or nonmelanocytic. If it is a melano erent sizes, though generally over 0.1 mm; brown, gray, or
cytic lesion, the physician must continue with the second black. They correlate with nests of melanocytes in the area
step, which means differentiating a benign melanocytic of the dermoepidermal junction (Figs. 6.6 to 6.9).
lesion from a melanoma.
Therefore, in order to proceed to the second step, it is Streaks or Projections
essential to know the different criteria that may be used to At present, we include branching (radial streaming) and
determine if a pigmented lesion is melanocytic or not. pseudopods under this name.
These criteria are: Branching (radial streaming) are radial extensions in
•• Pigment network the pigment network at the periphery of the lesions.
•• Aggregated globules Pseudopods are radial projections of the pigment
•• Streaks or projections network in the periphery of the lesion and invading appa
•• Homogeneous blue pigmentation rently healthy skin. They are thicker than branching and
•• Parallel pattern have a bulbous end.
Both branching and pseudopods are expressions of an
Pigment Network
altered pigment network.
Pigment network consists of brown or black lines with Histologically, they correspond to nests of melano
a reticular or grid appearance on a lighter background, cytes in lineal arrangement located in the dermoepidermal
resembling “holes”. From a histologic point of view, it rep junction (Figs. 6.10 to 6.13).
resents the rete ridges of the epidermis. The holes corres
pond to pigmented cells in the area of the dermal papilla,
Homogeneous Blue Pigmentation
while the lines correspond to the cells located in the inter This is a blue–gray area lacking structural components. In
the histologic correlation, the melanocytes are located in
papillary area. In this manner, it is possible to observe
the middle and deep dermis (Fig. 6.14).
lines and holes that may be very similar to or different
from each other, of different color, width and size, giving Parallel Pattern
rise to a typical pigment network (in benign melanocytic It can be seen in acral lesions. Depending on the localiza
lesions) or an atypical one (melanoma) (Figs. 6.1 to 6.5). tion of the melanocytic cells, the dermatoglyphics ridges
Fig. 6.1: Pigment network. Fig. 6.2: Pigment network (arrows).

Fig. 6.3: Pigment network histopathological correlation (red arrow— Fig. 6.4: Pigment network (arrows).
holes; black arrow—lines).
Fig. 6.5: Pigment network (arrow). Fig. 6.6: Aggregated globules (arrow).
Fig. 6.7: Aggregated globules: histopathological correlation—nests of Fig. 6.8: Aggregated globules (arrows).
melanocytes in the area of the dermoepidermal junction (arrow).
Fig. 6.9: Aggregated globules (arrow). Fig. 6.10: Streaks or projections (arrow).
Fig. 6.11: Streaks or projections: histopathological correlation—nests Fig. 6.12: Streaks or projections (arrow).
of melanocytes in lineal arrangement located in the dermoepidermal
junction (arrow).
Fig. 6.13: Streaks or projections (arrow). Fig. 6.14: Homogeneous blue pigmentation.
or furrows may be pigmented. In this manner, there are Dots

two parallel patterns, the ridge pattern and the furrow one These are round structures, <0.1 mm, black, brown, or
(Figs. 6.15 to 6.18). blue-gray. Color depends on the location of the pigment:
stratum corneum, epidermis, or dermis (Figs. 6.19 and 6.20).
Additional Criteria for Melanocytic Lesions
Regression
It is possible to observe other criteria in melanocytic
lesions, but they also occur, on occasion, in nonmela This corresponds to white areas (histologically, fibrosis)
nocytic ones. Thus, they are not considered absolute cri and blue areas (histologically, melanosis or melano
phages). The latter may present blue peppering appear
teria for melanocytic lesions. Nevertheless, when they
ance. Clinically, they correspond to the nonelevated part
are accompanied by the criteria previously described for
of the lesion (Figs. 6.21 to 6.24).
melanocytic lesions, they acquire a great significance to
the diagnosis. Blue-White Veil
These features are dots, regression, whitish veil, and This is represented by areas lacking irregular structures,
hyperpigmented stains. of color blue, blue-gray or whitish blue, with ground glass
Fig. 6.15: Parallel furrow pattern (arrow). Fig. 6.16: Schematic representation of the anatomy of the skin in acral
zones.
Fig. 6.17: Parallel furrow pattern (arrow). Fig. 6.18: Parallel ridge pattern (arrow).
Fig. 6.19: Dots (arrows). Fig. 6.20: Dots: histopathological correlation—aggregated melanocytes
or granules of melanin in the stratum corneum, epidermis, or dermis.
Fig. 6.21: Regression: melanosis (red arrow); fibrosis (black arrow). Fig. 6.22: Regression: histopathological correlation—fibrosis (white
scar-like) (arrow).
Fig. 6.23: Regression: histopathological correlation—melanosis (blue- Fig. 6.24: Regression (arrow).
gray areas)
appearance. From a clinical point of view, blue-white veil

corresponds to the raised parts of the lesion. From a his
tologic point of view, it is possible to observe orthokera
tosis and deeply pigmented cells in the superficial dermis
(Figs. 6.25 to 6.28).
Hyperpigmented Areas
These are pigment areas that do not allow the recognition
of any structure within. They may be localized or diffuse;
regular or irregular; and of color black, dark brown, or gray.
They are due to a large concentration of melanin throughout
the epidermis and/or dermis (Figs. 6.29 to 6.31).
Fig. 6.25: Blue-white veil (arrow).
Fig. 6.26: Blue-white veil: histopathological correlation—orthokera Fig. 6.27: Blue-white veil (arrow).
tosis and deeply pigmented cells in the superficial dermis.
Fig. 6.28: Blue-white veil (arrow). Fig. 6.29: Hyperpigmented areas (arrow).
Fig. 6.30: Hyperpigmented areas: histopathological correlation—due Fig. 6.31: Hyperpigmented areas (arrow).
to a large concentration of melanin throughout the epidermis and/or
dermis.
SUGGESTED READING
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea
of Dermoscopy. Milán: EDRA Medical Publishing & New ciones Gráficas; 2009.
Media; 2000. Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; Taylor & Francis; 2005.
2000. Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
Ediciones Journal; 2012. Company; 1996.
Guide, 2nd edition. McGraw-Hill Education; 2015.
Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment mented Skin Lesions. An Atlas Based on the Consensus Net
Guide, 2nd edition. New York: McGraw-Hill Education; 2015. Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat New Media; 2001.
tern Analysis 2011 Facultas Verlags- und Buchhandels AG Stolz W, Braun-Falco O, Bilek P, et al. Color atlas of Dermatos
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at. copy. Germany: Blackwell Science; 1994.
Lallas A. Dermoscopy in general dermatology. Dermatol Clin. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
2013;3:679-94. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016
6.2 NEVOGÉNESIS
Aimilios Lallas, Zoe Apalla, Elvira Moscarella, Caterina Longo, Teresa Deinlein, Iris Zalaudek
The formation and evolution of nevi is, to a large extend, of melanocytes in the epidermis might lead to the forma
genetically determined, being though influenced also by tion of a nevus from dermal melanocytes (“constitutional”
environmental factors.1 pathway; Fig. 6.33). This pathway is minimally, or not at
Since the middle of the previous century it has been all, affected by environmental factors. Instead, melano
clarified that melanocytes do not derive from keratino cytes that have normally migrated into the epidermis
cytes, but are of neural crest origin.2 For decades, nevi might later proliferate in response to exogenous factors
have been thought to originate from proliferating epider [like ultraviolet (UV) radiation], giving rise to nevi of epi
mal melanocytes, which later in life extend into the der dermal origin (“acquired” pathway; Fig. 6.34). In simple
mis, where eventually they follow a regressive process.3 words, nevi might develop early, within the dermis and
This traditional model of downward migration has been independent of the environment, or later, in the epidermis
challenged by the modern stem cell theory and by novel and in response to environmental factors (Table 6.1).5
insights into the morphology of nevi, provided by dermos Several morphologic, genetic, and epidemiological
copy and newer imaging techniques like reflectance con data support this dual concept. Dermoscopy brought to
focal microscopy (RCM).4 light novel information on the morphology of nevi and
dermoscopic criteria have been shown to perfectly cor
Two Pathways of Nevogénesis relate to histopathologic alterations.4 Dermoscopically,
Combining all the aforementioned novel information, the majority of nevi are known to display either a globular
a dual concept of nevogénesis has been recently intro or a reticular pattern, with the globules corresponding to
duced.5 According to it, nevi might be either of dermal ori dermal nests of melanocytes and the pigment network
gin, formed via the “constitutional” pathway, or of epider corresponding to a lentiginous junctional proliferation
mal origin, formed via the “acquired” pathway. This dual (Figs. 6.35 and 6.36).6 Recent evidence suggests that the
concept is mainly based on the knowledge that precursor globular and reticular dermoscopic patterns do not only
(stem) cells first differentiate into melanocytes within the represent two morphologic variants, but characterize two
dermis and, then, epidermal chemotactic factors guide subgroups of nevi with clearly distinct epidemiological
their migration in the epidermis (Fig. 6.32).2 During this pro characteristics and different biology. For example, glob
cedure, a disturbance or delay of the “upward” migration ular nevi are known to remain relatively stable during
Fig. 6.32: Route of melanocyte migration in the skin. Fig. 6.33: Constitutional pathway of nevogénesis. A disturbance or
delay of the “upward” migration of melanocytes in the epidermis leads
to the formation of a nevus from dermal melanocytes.
Table 6.1: Dual concept of nevogénesis.

Constitutional
pathway Acquired pathway
Dermoscopic pattern Globular Reticular
Age Embryonic life and Late childhood and
early childhood adulthood
Anatomic sites Head/neck and Extremities
upper trunk
Environmental No Yes
factors
Duration Long (ofter a From 20s/30s to 60s
lifetime)
Fig. 6.34: Constitutional pathway of nevogénesis. Melanocytes that

have normally migrated into the epidermis proliferate in response
to exogenous factors (like ultraviolet radiation), giving rise to nevi of
epidermal origin.
Fig. 6.35: Dermoscopic globules histopathologically correspond to Fig. 6.36: Dermoscopic pigment network histopathologically corres
dermal nests of melanocytes. ponds to lentiginous melanocytic proliferation at the level of the
dermoepidermal junction.
lifetime, while reticular nevi appear later and involute predominating in children and the reticular pattern in
earlier, being exceptionally uncommon in elderly patients adults (Fig. 6.39).7 In more detail, virtually all congenital
(Figs. 6.37 and 6.38).7,8 Furthermore, there is a significant nevi display a globular pattern (the “cobblestone” is a vari
difference between globular and reticular nevi regarding ation of the globular pattern), as do also the nevi developing
their distribution on the body sites.8 All these observations in early childhood, which is in line with the hypothesis
originated mainly from dermoscopic studies seem to be that nevi appearing within the first years of life are in fact
adequately explained by the dual concept of nevogénesis congenital nevi that become evident a few months or years
described above. later. This strong correlation between the globular der
It has been shown that the dermoscopic pattern of nevi moscopic pattern and young age is absolutely consistent
is significantly influenced by age, with the globular pattern with the “constitutional” pathway of nevogénesis, which
Fig. 6.37: Evolution of globular nevi throughout lifetime. Fig. 6.38: Evolution of reticular nevi throughout lifetime.
Fig. 6.39: Age-related nevus patterns.
suggests that an early perturbation or delay of the upward In contrast, reticular nevi are suggested to originate
migration of melanocytes results in their retention within at a later stage, from melanocytes, which have normally
the dermis, giving rise to dermal nevi.5 Moreover, dermo migrated from the dermis to the epidermis or reached
scopic studies suggest that globular nevi mainly develop at least the dermoepidermal junction. These nevi may
on the head/neck area and on the upper trunk, while retic develop in response to both endogenous and exogenous
ular nevi prevail on the extremities.8 At the same time, the factors, such as growth hormones during puberty and UV
melanoblast migration is known to follow a cephalocaudal radiation. Indeed, it has been shown that the total nevus
and proximal-to-distal sequence.1 In simple words, the count correlates with sun exposure.9 Reticular nevi are
precursor cells of melanocytes arrive earlier on the head/ dynamic tumors, typically developing from early child
neck and finally on the extremities. The two latter obser hood until midlife and afterward, the majority of them,
vations are perfectly combined in the proposed “constitu involuting, so that they are rarely seen in elderly indivi
tional” pathway of nevogénesis, since globular nevi (which duals.4,9
are proposed to result from an early disturbance) tend to While the dual concept of nevogénesis seems to per
develop exactly on the body sites where melanoblasts fectly correlate with the dermoscopic morphology of
arrive early in embryonic life. globular and reticular nevi, it is inadequate to explain the
existence of nevi with a mixed dermoscopic pattern, REFERENCES

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generated speculations on the possibility of a similar con The epidermal and dermal origin of melanocytic tumors:
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emerging topic of research. Accumulating data from new 13. Bauer J, Garbe C. Acquired melanocytic nevi as risk factor
studies aiming to correlate morphology with the genetic for melanoma development. A comprehensive review of
epidemiological data. Pigment Cell Res. 2003;16:297-306.
background of nevi and melanoma are expected to further 14. Liu W, Dowling JP, Murray WK, et al. Rate of growth in mel
shed light in the field and deepen our understanding of the anomas: characteristics and associations of rapidly growing
biology of melanocytic lesions. melanomas. Arch Dermatol. 2006;142:1551-8.
6.3 CONGENITAL MELANOCYTIC NEVI

Horacio A Cabo
The term “melanocytic nevi” comprises a heterogeneous general, and congenital nevi in particular, present three
group of benign melanocytic proliferations with different basic dermoscopic patterns. At the same time, these three
epidemiologic, clinical, dermoscopic, and histopathologic basic patterns may show variants.
characteristics. Within this ample spectrum, it is possi The basic patterns are:
ble to distinguish two main characteristics: congenital •• Reticular pattern
melanocytic nevi (CMN) and acquired melanocytic nevi •• Globular pattern
(AMN). The former include also blue nevus and spilus •• Mixed pattern
nevus, while the latter comprise junction nevus, com –– Central
pounded and intradermal, Clark’s nevus (also known as –– Peripheral
dysplastic or atypical nevus), and Spitz nevus. Reticular pattern: The pigment network extends over
Congenital melanocytic nevi are benign nevocytic the whole lesion with similar features as regards shape
hamartomas arising from a congenital malformation in and color (Figs. 6.40A to E).
which there appears to be a precocious terminal differen •• Variant: Patched reticular pattern: Pigment network
tiation of the melanocytic precursors and/or a blockage of areas alternating with areas without pigment network,
the migration at the dermal or hypodermal levels. Their usually skin-colored (Figs. 6.41A to C).
cells derive from the neural crest. Globular pattern: Globules distributed over the entire
In general, CMN are present at birth, although they lesion with similar features regarding shape, size, and
may become evident months or even years later. They color (Figs. 6.42A to C).
affect 1–6% of the general population. According to their •• Variant: Cobblestone pattern: A globular pattern where
size, they are classified into: small (<1.5 cm), medium
the globules are large and angulated (Figs. 6.43A and B).
(1.5–20 cm), and large or giant (>20 cm).
In the giant forms, which are rare, there is a 5–20% pos Mixed pattern: Presence of both reticular and globular pat
sibility that a melanoma will develop. terns in the same lesion. Globule location defines whether
Their clinical appearance is varied from a simple macula it is central or peripheral.
or raised pigmented tumor, either smooth or verrucous, •• Central mixed pattern: Globules in the central area and
with or without hair, and small in size, to the involvement pigment network in the periphery (Figs. 6.44A and B).
of large anatomical areas. Color usually ranges from light –– Variant: Hyperpigmented: The central globules are
brown to dark brown or black. highly pigmented and a brown zone can be seen in
Congenital melanocytic nevi have their own histologic the central area (Fig. 6.45).
features that differentiate them from AMN: –– Hypopigmented: The central globules show little
•• Nevus cell nests in reticular dermis and hypodermis pigment and there is a central whitish or skin-
•• Adnexal, vascular, and/or neural involvement colored area (Figs. 6.46A to C).
•• Arrangement of nevocytes between fibers of dermal •• Peripheral mixed pattern: Globules in the peripheral
collagen area. This variant can be observed in young people
The nevoid cell nests are accompanied by other ham and is related to the nevi growth. In general, there are
artomatous structures, such as hair follicles, sebaceous one to three lines of globules. These should not appear
glands, and fatty tissue, among others. in adults, since at maturity nevi have to remain stable
In some CMN, the histology is similar to that of acquired (Figs. 6.47A to D).
melanocytic nevus, especially the small ones.
Other Variants
Small CMN Homogeneous pattern: Homogeneous brown lesions, due
Both from a clinical and a dermoscopic point of view, small to an even pigmentation over the entire lesion, which
CMN are generally indistinguishable from Clark’s nevi. prevents structure distinction (Figs. 6.48A to D).
With the exception of Spitz nevus and blue nevus (see Half and half pattern: Half globules and half pigment
Spitz nevus and Blue nevus and Combined nevus), nevi in network (Figs. 6.49A to D).
A B
C D
E Figs. 6.40A to E: Reticular pattern.

A B
C Figs. 6.41A to C: Patched reticular pattern.
A B
Figs. 6.42A and B
C Figs. 6.42A to C: Globular pattern.
A B
Figs. 6.43A and B: Cobblestone pattern.
A B
Figs. 6.44A and B: Central mixed pattern.
Fig. 6.45: Hyperpigmented central mixed pattern.
A B
C Figs. 6.46A to C: Hypopigmented central mixed pattern.

A B
C D
Figs. 6.47A to D: Peripheral mixed pattern.
A B
Figs. 6.48A and B
C D
Figs. 6.48A to D: Homogeneous pattern.
A B
C D
Figs. 6.49A to D: Half and half pattern.
Multicomponent pattern: Presence of three or more In relation with the reticular pattern:
dermoscopic structures. It is associated with atypical nevi •• Lineal network fragments (fungal hypha-like) (Figs.
or melanoma (Figs. 6.50A to C). 6.53 to 6.55)
It is very important to know the different dermoscopic In relation with the globular pattern:
patterns of the nevi and to be able to distinguish them •• Cobblestone pattern (see Fig. 6.43)
from the dermoscopic patterns for melanoma. •• Target globules (globules within the network gaps)
On the basis that nevi are nevi and melanoma is (Figs. 6.56 and 6.57)
melanoma, and that nevi do not become melanomas, Other features present in CMN include:
follow-up of patients with multiple nevi is easier if we know •• Milia-like cysts: Round yellow-white small structures
the patient’s nevi type, also known as nevi signature pattern. that correspond to intraepidermal keratin accumula
tion).
Medium, Large, and Giant CMN •• Hypertrichosis: This means an increase in terminal
(Figs. 6.51 to 6.58) hairs (Figs. 6.58A to C).
There are some dermoscopic structures mostly observed •• Perifollicular pigmentary changes: Hyperpigmentation
in CMN, which appear from infancy or at birth. or hypopigmentation around the hair follicle.
A B
C Figs. 6.50A to C: Multicomponent pattern.

Fig. 6.51: Medium congenital melanocytic nevus.
A B
C Figs. 6.52A to C: Giant congenital melanocytic nevus.

Fig. 6.53: Lineal network fragments (fungal hypha-like) (red circle). Fig. 6.54: Lineal network fragments (fungal hypha-like) at the periphery
of the lesion.
Fig. 6.55: Lineal network fragments (fungal hypha-like) throughout Fig. 6.56: Target globules (red circle).
the lesion.
Fig. 6.57: Close-up target globules (arrow).

A B
C Figs. 6.58A to C: Congenital nevus with hypertrichosis.
SUGGESTED READING Kopf AW, Bart RS, Hennessey P, et al. Congenital nevocytic nevi
and malignant melanomas. J Am Acad Dermatol. 1979;1:123.
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Lallas A. Dermoscopy in General Dermatology. Dermatol Clin.
of Dermoscopy. Milán: EDRA Medical Publishing & New 2013;3:679-94.
Media; 2000. Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; ciones Gráficas; 2009.
2000.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
Ediciones Journal; 2012. copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
Ingordo V, Iannazzone SS, Cusano F, et al. Dermoscopic features Company; 1996.
of congenital melanocytic nevus and Becker nevus in an Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
adult male population: an analysis with a 10-fold magnifica American Academy of Dermatology; 1999.
tion. Dermatology. 2006;212:354-60. Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment mented Skin Lesions. An Atlas Based on the Consensus Net
New Media; 2001.
Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
(MOABT). New York: Elsevier Ltd; 2004. copy. Germany: Blackwell Science; 1994.
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of non-
tern Analysis. Austria: Facultas.wuv; 2011. pigmented skin tumors. Boca Raton, FL: CRC Press; 2016.
6.4 ACQUIRED MELANOCYTIC NEVI

Horacio A Cabo
As previously mentioned, the term melanocytic nevi •• Variant: Patched reticular pattern: Areas with pigment
comprises a heterogeneous group of benign melanocytic network alternating with areas without pigment
proliferations with different epidemiologic, clinical, der network and usually skin-colored (Fig. 6.60).
moscopic, and histopathologic features. We can classify Globular pattern: Globules distributed in the entire lesion
them into two main categories: congenital melanocytic with similar features regarding shape, size, and color
nevi (CMN)—including blue nevi and spilus nevi—and (Fig. 6.61).
acquired melanocytic nevi (AMN). The latter conform a •• Light or dark brown nevi depending on phototype.
group comprising junction, compound and intradermal •• This pattern is more frequently observed in CMN.
nevi, Clark nevus (also known as dysplastic nevus or atyp •• Variant: Pebbled pattern: This is a globular pattern
ical nevus), and Spitz nevus. where the globules are bigger and angulated. It is
Acquired melanocytic nevi are melanocytic prolife mostly found in CMN (Fig. 6.62).
rations that are not present at birth. These nevi show a
Mixed pattern: It is characterized by the presence of both
dynamic vital cycle starting at puberty and reaching its
reticular and globular patterns in the same lesion. The
maximum incidence in the fourth and fifth decades of
location of the globules determines whether it is central or
life. However, in the sixth and seventh decades their num
peripheral.
ber decreases. There is evidence to support the idea that
•• Central mixed: Globules in the central part and pigment
these nevi develop as a result of exposure to UV rays, and
network in the periphery (Fig. 6.63).
in other cases owing to hereditary factors (atypical nevus
–– Hyperpigmented variant: The central globules are
syndrome). Acquired melanocytic nevi may vary signifi
highly pigmented and only a brown area can be
cantly in number, color, size, and/or clinical characteristics.
observed at the center of the lesion (Fig. 6.64).
A great number of common nevi or Clark nevi points to a
–– Hypopigmented variant: The central globules show
high risk of melanoma development.
little pigmentation and a whitish or skin-colored
Color is very important in dermoscopy, especially in
area is observable at the center of the lesion
melanocytic lesions. Clearly, most of these lesions will be
(Fig. 6.65).
in different shades of brown. Other colors will depend on
•• Peripheral mixed: Globules in the peripheral area. This
the localization of the pigment and blood vessels. Some
nevi in people with high phototypes will be darker while pattern is seen in young people and is related to the
growth of the nevi. In general, there are between one
others, in phototypes I or II, will be lighter.
and three lines of globules. It should not be found in
Dermoscopic Classification of AMN adults, since at this time of life nevi are supposed to
remain stable (Figs. 6.66A and B).
Like CMN, AMN also present three basic dermoscopic
patterns. At the same time, these three basic patterns may Other Variants
present variants. Homogeneous pattern: Homogeneous brown lesions, due
The basic patterns are: to a uniform pigmentation over the entire lesion, which
•• Reticular pattern
impedes the observation of structures (Fig. 6.67).
•• Globular pattern Half and half pattern: Half globules and half pigment
•• Mixed pattern network (Fig. 6.68).
–– Central Multicomponent pattern: Three or more desmoscopic
–– Peripheral structures present. It is associated with atypical nevi or
Reticular pattern: The pigment network appears in the melanoma (Fig. 6.69).
entire lesion, presenting similar features as regards form It is very important to know the different dermoscopic
and color. This is generally in different shades of brown. patterns of the nevi and distinguish them from those of
Nevi appearing in youth and in response to sun exposure melanoma (see Management of Patients with Multiple
frequently present this pattern (Figs. 6.59A to C). Nevi).
A B
C Figs. 6.59A to C: Acquired melanocytic nevi with reticular pattern.
Fig. 6.60: Acquired melanocytic nevi with patched reticular pattern.

Fig. 6.61: Acquired melanocytic nevi with globular pattern. Fig. 6.62: Acquired melanocytic nevi with globular (pebbled) pattern.
Fig. 6.63: Acquired melanocytic nevi with mixed central pattern. Fig. 6.64: Acquired melanocytic nevi with mixed central hyperpig
mented pattern.
Fig. 6.65: Acquired melanocytic nevi with mixed central hypopigmented

central pattern.
A B
Figs. 6.66A and B: Acquired melanocytic nevi with peripheral mixed pattern.
Fig. 6.67: Acquired melanocytic nevi with homogeneous pattern. Fig. 6.68: Acquired melanocytic nevi with half and half pattern.
Fig. 6.69: Acquired melanocytic nevi with multicomponent pattern.

SUGGESTED READING Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea

Media; 2000. Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
2000. Company; 1996.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
Ediciones Journal; 2012. American Academy of Dermatology; 1999.
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
Guide, 2nd edition. New York: McGraw-Hill Education; 2015. mented Skin Lesions. An Atlas Based on the Consensus Net
Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
(MOABT). New York: Elsevier Ltd; 2004. New Media, 2001.
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
tern Analysis. Austria: Facultas.wuv; 2011. copy. Germany: Blackwell Science; 1994.
2013;3:679-94. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
6.5 ATYPICAL NEVUS (DYSPLASTIC)

Horacio A Cabo
Atypical nevi (AN) are those sharing all or some of the difficult to distinguish the different types of nevi clinically,
characteristics of melanoma of the clinical ABCD rule and besides some nevi are clinically atypical but are not so
(Asymmetric lesion, irregular Borders, multiple Colors, under dermoscopic examination. Therefore, under clinical
and a Diameter >0.7 mm). and dermoscopic examination we face different scenarios.
The term AN is a clinical term. Some of these AN
Clinical Definition of AN
under clinical examination, may present, histologic
features different from those of common nevi and are Atypical nevi sharing some or all ABCD characteristics of
called dysplastic. melanoma (Fig. 6.70).
It is then clear that clinical atypia may or may not be Dermoscopic Definition of AN
correlated to histologic dysplasia.
•• Clinically AN with benign dermoscopic patterns (see
Therefore, dysplastic nevi (DN) must be regarded as
Congenital Melanocytic Nevi and Acquired Melano
histologic variants of common nevi.
cytic Nevi). These patterns include:
That is to say, atypical–DN do not become nor are they
–– Reticular pattern
precursors of melanoma.
–– Globular pattern
Nevi are nevi and melanoma is melanoma. Primary
–– Mixed pattern
melanoma appears in the skin in two ways: de novo
▪▪ Central
(around 70%) or growing on a nevus (around 30%) and in
▪▪ Peripheral
these latter cases about 60% are common or not AN.
•• Clinically AN with indefinite dermoscopic patterns
The presence of multiple nevi and DN is a genetic risk
–– These nevi present a dermoscopic pattern known
marker for cutaneous melanoma.
as multicomponent, where it is possible to observe
Histologic dysplasia may be mild, moderate, or severe.
three or more dermoscopic criteria.
In patients with AN and severe dysplasia, the excision
–– It is possible to see a wide range of alterations
margin must be extended, not because they may be mel
–– Mild alterations: Suitable for short-term digital
anoma precursors, but because it is occasionally difficult
dermoscopy follow-up with sequential images
to distinguish them from melanoma, both clinically and
(Figs. 6.71 to 6.75).
dermoscopically, and even histologically.
Obviously, prophylactic excision of clinically AN does
not reduce the risk of melanoma.
There are no doubts that the clinical acronym ABCD
has failed when it comes to differentiating melanoma from
DN, especially because by definition, both lesions share
the same characteristics. However, dermoscopy offers a
means to distinguish malignant from benign lesions in
clinically indeterminate cases. The presence or absence of
specific dermoscopic structures and patterns may help the
dermatologist to decide which lesions may be controlled
by means of short- or long-term monitoring and which
ones require a biopsy.
Dermoscopy improves clinical diagnosis because it
enables us to see structures that are not visible with the
naked eye.
Thus, with the dermoscope we can recognize der Fig. 6.70: Atypical nevus—clinical view (arrow). The clinical ABCD rule
moscopic characteristics of the different types of nevi is positive (asymmetry, irregular borders, multiple colors, and 0.9 mm
of diameter).
and distinguish them from melanoma. In contrast, it is
A B
Figs. 6.71A and B: Atypical nevus (mild dysplasia) with different colors (black, gray, dark brown, and light brown) atypical pigment network (red
arrow) and eccentric pigmentation (black arrow).
Fig. 6.72: Atypical nevus (mild dysplasia) with atypical pigment Fig. 6.73: Atypical nevus (mild dysplasia): asymmetric lesion with
network. eccentric areas of regression (arrow).
Fig. 6.74: Atypical nevus (mild dysplasia): areas of regression (red Fig. 6.75: Atypical nevus (mild dysplasia): atypical pigment network
arrows); atypical pigment network (black arrow); and negative (red arrow); irregular streaks (black arrow); and irregular brown
pigment network (white arrow). globules (white arrow).
–– Severe alterations: Very difficult to differentiate ▪▪ Irregular projections/streaks

from melanoma and requiring biopsy. These der ▪▪ Blue whitish-veil
moscopy features include (Figs. 6.76 to 6.82): ▪▪ Irregular dots and globules
▪▪ Atypical pigment network ▪▪ Regression
▪▪ Negative pigment network ▪▪ Multiple colors
Fig. 6.76: Atypical nevus (severe dysplasia): irregular streaks (red Fig. 6.77: Atypical nevus (severe dysplasia) with atypical pigment
arrow); atypical pigment network (white arrow); and asymmetric network.
pigmentation (black arrow).
Fig. 6.78: Atypical nevus (severe dysplasia): atypical pigment network Fig. 6.79: Atypical nevus (severe dysplasia): atypical negative network
(red arrow); regression (black arrow). (red arrows); regression (black arrow).
Fig. 6.80: Atypical nevus (severe dysplasia): red dots with irregular Fig. 6.81: Atypical nevus (severe dysplasia): multiple brown globules
distribution (red arrow); atypical negative network (white arrow); and with irregular distribution (red arrow); irregular streaks (black arrow);
lineal irregular vessels (black arrow). and regression (white arrows).
Fig. 6.82: Atypical nevus (severe dysplasia): irregular streaks (red

arrow); atypical pigment network (black arrow); regression (white
arrow); ulceration (yellow arrow); and brown globules with irregular
distribution (green arrow).
SUGGESTED READING
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Duffy K, Grossman D. The dysplastic nevus: from historical per
of Dermoscopy. Milán: EDRA Medical Publishing & New spective to management in the modern era. Part 2 Molecu
Media; 2000. lar aspects and clinical management. J Am Acad Dermatol.
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; 2012;67(1):19.e1-32.
2000. Hoffmann-Wellenhof R, Blum A, Wolf IH, et al. Dermoscopic
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: classification of atypical nevi (Clark Nevi). Arch Dermatol.
Ediciones Journal; 2012. 2001;137:1575-80.
Duffy K, Grossman D. The dysplastic nevus: from historical per Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment
spective to management in the modern era. Part 1 Histor Guide, 2nd edition. New York: McGraw-Hill Education; 2015.
ical, histologic and clinical aspects. J Am Acad Dermatol. Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials
2012;67(1):1.e1-18. (MOABT). New York: Elsevier Ltd, 2004.
Kittler H, Tschandl P. Dysplastic nevus: why this term should Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
be abandoned in dermatoscopy. Dermatol Clin. 2013;31: American Academy of Dermatology; 1999.
579-88. Rosendahl C, Grant-Kels JM, Que SK. Dysplastic nevus: facts and
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat fiction. J Am Acad Dermatol. 2015;73:507-12.
tern Analysis. Austria: Facultas.wuv; 2011. Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
Lallas A. Dermoscopy in General Dermatology. Dermatol Clin. mented Skin Lesions. An Atlas Based on the Consensus Net
Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
2013;3:679-94.
New Media; 2001.
Stolz W, Braun-Falco O, Bilek P, et al. Color atlas of Dermatos
ciones Gráficas; 2009. copy. Germany: Blackwell Science; 1994.
Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London: Strazzula L, Vedak P, Hoang MP, et al. The utility of re-excising
Taylor & Francis; 2005. mildly and moderately dysplastic nevi: a retrospective analy
Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Mic sis. J Am Acad Dermatol. 2014;71:1071-6.
roscopy of Pigmented Skin Lesions. Sydney: McGraw-Hill Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
Book Company; 1996. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
6.6 SPITZ NEVUS

Stefano Caccavale, Alessio Gambardella, Amalia Lupoli, Gabriella Brancaccio, Giuseppe Argenziano
Clinical Features The dermoscopic patterns of spitzoid lesions were

Spitz nevi can occur in any body site. The most frequent first described by Pehamberger et al. in 1987 and later
location is on the limbs, particularly the lower limbs (30– reviewed by several authors. The main dermoscopic pat
41% of cases). Spitz nevi can present as macules, papules, terns ascribed to Spitz nevi are six, namely the reticular,
nodules, or plaques and their size is usually <6 mm, rarely globular, starburst, homogenous and atypical patterns,
exceeding 10 mm. for pigmented lesions, and the vascular pattern (homoge
The hypopigmented variant is defined as the “classic” nous pink pattern, dotted vessels, and inverse network) in
type and is characterized by a pink-reddish appearance hypopigmented or amelanotic lesions. Dermoscopically,
because of its abundant vascularity. This variety usually the globular and the starburst are the two predominant
arises as a fast growing nodule or papule and is often patterns; the former is more frequently associated with
located in the head–neck district (especially among classical Spitz nevi, while the latter characterizes Reed
infants and younger patients). The majority of Spitz nevi nevi. Less common dermoscopic patterns are the homo
are pigmented. The pigmented type shows a brown-to- geneous black pattern, the homogeneous pink pattern
black appearance and is more common in adults. (with dotted or irregular vessels), and the inverse network
Currently, pigmented Spitz nevi are excised more pattern (with interconnected hypopigmented serpiginous
frequently than classical pink Spitz nevi. This may be due lines, which form a network that circumscribes irregular
to the improved ability to recognize pigmented Spitz nevi pigmented globular-like structures or dotted vessels and
using dermoscopy. The “pink” nodular Spitz nevi have the which can be associated with crystalline or chrysalis struc
highest chances of manifesting atypical histopathological tures). However, 20% of Spitz nevi dermoscopically exhibit
features. Although infrequent, these pink Spitz nevi are an atypical or multicomponent pattern, characterized by
also the ones that most frequently contribute to the group an asymmetric or disorganized distribution of structures
of “atypical Spitz nevi/tumors”. Spitzoid neoplasms are and colors and by pigmented structures suggestive of mel
usually asymptomatic and have a sudden onset, with a anoma.
relatively fast growth and visible changes in size (Figs. Most of these different dermoscopic patterns proba
6.83A and B). bly represent different phases of the natural evolution of
Spitz nevi. In the growing phase, pigmented Spitz nevi can
Dermoscopic Criteria evolve from a globular to a starburst pattern: they reveal
In the last 20 years, dermoscopy has become the practi regular streaks, pseudopods, finger-like or globule-like pig
cal link between clinical dermatology and histopathology, mented projections regularly distributed on the periphery.
allowing the clinicians to visualize structures not discern The presence of streaks is not pathognomonic in Spitz nevi
able by the naked eye. In order to confirm the diagnosis of a because they can also be found in melanoma, represent
Spitz nevus, dermoscopy represents a useful tool, although ing the tendency of both tumors to grow horizontally. After
histopathology is often mandatory. Dermoscopy has con a variable number of months, the peripheral projections
tributed significantly to improving the clinical diagnosis disappear and the lesion becomes stable, manifesting a
of pigmented and nonpigmented Spitz nevi and, more homogenous pattern, typified by structureless brown-to-
recently, digital dermoscopic follow-up has allowed a bet black pigmentation. After a variable number of years, when
ter understanding of the evolution of this peculiar group of the lesion enters an apparent state of senescence, it mani
nevi. The diagnostic accuracy of Spitz nevi has been shown fests loss of pigment and undergoes spontaneous involu
to increase from 56 to 93% with the use of dermoscopy tion. Spontaneous involution seems, therefore, a plausible
compared to the naked eye alone. Moreover, the better explanation for the epidemiologic data reporting the fre
clinical recognition due to dermoscopy has contributed quency of Spitz nevi as being inversely correlated to patient
significantly to find out that Spitz nevi are pigmented in age. Not only pigmented but also nonpigmented Spitz nevi
about 70–90% of histopathologically examined cases. might go through spontaneous involution over time.
The dermoscopic recognition of amelanotic Spitz nevi periphery (Figs. 6.85A and B). A globular pattern is found in
is much more difficult. Dotted vessels, tan globules, and about 22% of Spitz nevi but it can be found also in common,
reticular depigmentation are common findings but the congenital or acquired (Clark), melanocytic nevi. While
diagnosis should always be based on a combination of globules in common nevi are relatively small and brown,
clinical and dermoscopic features. After a growing phase globules in Spitz nevi are larger and more irregular in
of several months, the lesion starts to become smaller until terms of color and size. Histopathologically, globules cor
it finally disappears. Spitzoid melanoma can also display relate to nests of pigmented melanocytes located at the
some of these features (peripheral streaks, dotted vessels, dermoepidermal junction and/or the superficial dermis,
or inverse network), but it usually lacks the characteristic thus they can be found in melanoma as well.
symmetric shape of Spitz nevi.
Starburst Pattern
Reticular Pattern This is the most frequent pattern, being found in about
This pattern is characterized by a homogeneous and reg 53% of pigmented Spitz nevi (Figs. 6.86A and B). It may
ular pigment network covering most part of the lesion represent one of the morphologic stages in the evolution
(Figs. 6.84A and B). The network in Spitz nevi is typified of Spitz nevi and corresponds to the radial growth phase of
by a grid of black line segments (honeycomb-like) over a this lesion. In most cases, peripheral black to gray globules
tan to gray-blue background. This black network is due to are fused with the central body of the lesion (forming the
pigmented parakeratosis, which is thus partially remov so-called streaks, pseudopods, or radial streaming) and
able by tape stripping. This is different from the classic are responsible for the starburst appearance, similar to an
network found in Clark nevi, which is due to pigmented exploding star. When present, the starburst pattern allows
keratinocytes in the basal layer. In this case, the network a diagnostic sensitivity of >90%.
holes correspond to the tips of dermal papillae and the
network itself to the projection of the pigmented ridges to
Homogenous Pattern
the skin surface. This pattern is characterized by a diffuse, uniform, struc
tureless, pink, dark brown or black-bluish color, which fills
Globular Pattern most of the lesion and lacks evidence of clear-cut streaks
Pigmented Spitz nevi often present gray-brown, relatively at the periphery (Figs. 6.87A and B). It may correspond to
large globules, distributed throughout the lesion or at the the stable phase of a Spitz nevus.
A B
Figs. 6.83A and B: (A) Clinical image of a spitzoid melanoma. (B) Dermoscopy reveals a flat, hyperpigmented lesion with an atypical starburst
pattern.
A B
Figs. 6.84A and B: (A) Clinical image of a pigmented Spitz nevus. (B) Dermoscopy of a small, flat, hyperpigmented Spitz nevus with superficial
black network.
A B
Figs. 6.85A and B: (A) Clinical image of a Spitz nevus. (B) Dermoscopy reveals a pigmented Spitz nevus, with large brown globules and dotted
vessels.
A B
Figs. 6.86A and B: (A) Clinical image of a pigmented Spitz nevus. (B) A small Spitz nevus with stereotypical starburst pattern. The starburst
pattern in this lesion consists of streaks (pseudopods) around the entire perimeter of the lesion.
A B
Figs. 6.87A and B: (A) Clinical image of a pigmented Spitz nevus. (B) Pigmented Spitz nevus with a diffuse, uniform, structureless, dark brown
color.
A B
Figs. 6.88A and B: (A) Clinical image of a Spitz nevus. (B) Pigmented Spitz nevus with melanoma-like pattern, typified by irregular reticular
pattern, blue-white veil, and irregular globules.
Atypical Pattern atypical lesions. In this case, it is important to exclude the

diagnosis of amelanotic melanoma. The inverse network is
Features suggestive of melanoma are present in about
composed by interconnected hypopigmented lines, which
20% of Spitz nevi (Figs. 6.88A and B). The irregularity in
form a network circumscribing dotted vessels. Chrysalis or
the distribution of colors and structures, and the presence
crystalline structures may also frequently be seen under
of blue-white veil, black blotches, irregular streaks, and
polarized dermoscopy. They consist of shiny white lines
irregular globules make it difficult to differentiate a Spitz
orientated orthogonally to each other and correspond to
nevus from melanoma.
altered papillary dermal collagen.
Vascular Pattern
This pattern is more frequent in hypopigmented or amel
Unusual Variants of Spitz Nevi
anotic Spitz nevi. It consists of dotted vessels and inverse Some variants of Spitz nevi described mainly in their his
network (Figs. 6.89A and B). Dotted vessels, in most cases, topathological aspects have been reported rarely for their
tend to be regularly distributed throughout the lesion but, clinical and dermoscopic presentation. These are the des
in some cases, vessels acquire a nondotted morphology in moplastic, angiomatoid, and verrucous variants.
A B
Figs. 6.89A and B: (A) Clinical image of a Spitz nevus. (B) A small pink nevus with irregular vessels.
Desmoplastic Spitz nevi mainly are symmetrical and spectrum ranging from benign to clear-cut malignant
well circumscribed. They are difficult to differentiate from lesions, with AST placed in the middle of this spectrum.
dermatofibroma clinically, and from melanoma dermo Since the first description, by Smith and coworkers in 1989,
scopically. several studies have investigated the histopathologic
Angiomatoid Spitz nevi typically present as soli features of AST, but only few have described the clinical
tary papules on the extremities of young women and are and dermoscopic features of AST.
characterized by a distinctive dermal vascular prolifera Different clinical parameters have been used to dif
tion. They can commonly be mistaken for either vascular ferentiate classic Spitz nevi from AST. First of all, younger
tumors or regressing melanoma. On dermoscopy, almost age (<10 years) is associated with more probably benign
all cases show a prominent vascular pattern, mainly cons Spitz nevus; conversely, AST usually affect older ages
tituted of dotted and linear vessels. (10–20 years). Location is another important parameter,
Clinical and dermoscopic features of few verrucous with extremities being more likely related to Spitz nevi,
Spitz nevi have been described recently. In these cases, while the back is the main location of AST. Smaller size
the lesions showed clinical and dermoscopic features of a (<5–6 mm) is usually common in classic Spitz nevus, while
verruca vulgaris, a dermal nevus, or a melanoma. Under lesions >1 cm are likely to be atypical. Other benign fea
dermoscopy, comma vessels and brown background pigmen tures are the plaque silhouette, the symmetry in shape,
tation, commonly seen in dermal nevi, were not detected. and the well-defined borders. Conversely, AST often pres
Despite their unusual clinical features, they show reassur ent as an asymmetric, not uniformly colored, ulcerated,
ing morphological clues histologically, which allow the and raised tumor (Figs. 6.90A and B). Under dermoscopy,
differential diagnosis from an atypical spitzoid tumor. AST potentially show all the dermoscopic elements typical
of melanoma. A blue-white veil, resulting from deep der
Atypical Spitz Tumors mal pigmentation with overlying epidermal hyperplasia,
Atypical Spitz tumors (AST) are defined as melanocytic can often be seen. About half of AST are hypo- or nonpig
proliferations with intermediate histopathologic features mented and in these cases a typical spitzoid pattern can be
between Spitz nevi and spitzoid melanoma, carrying seen, typified by dotted vessels and reticular depigmenta
uncertain malignant potential. The exact clinicopatho tion. Consequently, our attitude is to excise nodular spit
logic definition of AST is a matter of ongoing debate zoid-looking lesions, independently of the patient’s age.
among dermatopathologists. Some opinion leaders assert
that only two diagnostic categories can be ascribed to spit Management and Prognosis
zoid lesions, namely, Spitz nevi and spitzoid melanoma. A classic pink or pigmented Spitz nevus appearing before
Others suggest that spitzoid lesions are on a morphobiologic the age of 12 years can be managed conservatively and
A B
Figs. 6.90A and B: (A) Clinical image of an atypical Spitz tumor. (B) Dermoscopy reveals a melanoma-like pattern, typified by blue-white veil and
an irregular tiered globular pattern.
monitored if it is relatively small (up to 1 cm) and shows no Barnhill RL, Barnhill MA, Berwick M, et al. The histologic
atypical clinical and dermoscopic features. The expected spectrum of pigmented spindle cell nevus: a review of 120
evolution of Spitz/Reed nevi includes a stabilization cases with emphasis on atypical variants. Hum Pathol. 1991;
22:52-8.
phase followed by a slow involution until disappearance.
Broganelli P, Titli S, Lallas A, et al. Spitz/Reed nevi: proposal of
In the absence of irregular changes in color, shape, or management recommendations by the Dermoscopy Study
size, a follow-up can be continued until the lesion enters Group of the Italian Society of Dermatology (SIDeMaST). G
senescence and/or manifests a homogenous pattern. In Ital Dermatol Venereol. 2014;149:601-6.
contrast, Spitz nevi developing in individuals >12 years, Brunetti B, Nino M, Sammarco E, et al. Spitz naevus: a proposal for
or spitzoid-looking lesions that are >1 cm, nodular, ulcer management. J Eur Acad Dermatol Venereol. 2005;19:391-3.
Ferrara G, Argenziano G, Soyer HP, et al. The spectrum of Spitz
ated, or otherwise atypical, even if seen during childhood,
nevi: a clinicopathologic study of 83 cases. Arch Dermatol.
should warrant excision. 2005;141:1381-7.
The management of AST is a matter of ongoing discus Kelley SW, Cockerell CJ. Sentinel lymph node biopsy as an
sion. Parameters associated with a bad prognosis in ASTs adjunct to management of histologically difficult to diag
seem to be ulceration, large size, asymmetry, and presence nose melanocytic lesions: a proposal. J Am Acad Dermatol.
of mitosis. In 2000, Kelley and Cockerell suggested that 2000;42:527-30.
Lallas A, Kyrgidis A, Ferrara G, et al. Atypical Spitz tumours and
sentinel lymph node (SLN) biopsy should be performed
sentinel lymph node biopsy: a systematic review. Lancet
along with wide excision for patients with AST. However, Oncol. 2014;15:e178-e183.
there are no data proving the benefit of performing SLN Marghoob A, Malvehy J, Braun R. Taylor & Francis Group. 2013;
biopsy and a conservative management strategy should be CRC press, 2nd edition.
applied in the vast majority of AST. Moscarella E, Al Jalbout S, Piana S, et al. The stars within the
melanocytic garden: unusual variants of Spitz nevi. Br J Der
matol. 2015;172:1045-51.
SUGGESTED READING Moscarella E, Lallas A, Kyrgidis A, et al. Clinical and dermoscopic
Argenziano G, Agozzino M, Bonifazi E, et al. Natural evolution of features of atypical Spitz tumors: a multicenter, retrospective,
Spitz nevi. Dermatology. 2011;222:256-60. case-control study. J Am Acad Dermatol. 2015;73(5):777-84.
Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of pig Neri I, Dika E, Ravaioli GM, et al. Spitz nevi: defining features
mented skin lesions: results of a consensus meeting via the and management in children. G Ital Dermatol Venereol.
Internet. J Am Acad Dermatol. 2003;48:679-93. 2014;149:675-82.
Paniago-Pereira C, Maize JC, Ackerman AB. Nevus of large spin Reed RJ, Ichinose H, Clark WH Jr, et al. Common and uncommon
dle and/or epithelioid cells (Spitz’s nevus). Arch Dermatol. melanocytic nevi and borderline melanomas. Semin Oncol.
1978;114:1811-23. 1975;2:119-47.
Pehamberger H, Steiner A, Wolff K. In vivo epiluminescence Requena C, Requena L, Kutzner H, et al. Spitz nevus: a clin
microscopy of pigmented skin lesions. I. Pattern analysis of icopathological study of 349 cases. Am J Dermatopathol.
2009;31:107-16.
pigmented skin lesions. J Am Acad Dermatol. 1987;17:571-83.
Smith KJ, Barrett TL, Skelton HG 3rd, et al. Spindle cell and epi
Peris K, Ferrari A, Argenziano G, et al. Dermoscopic classification thelioid cell nevi with atypia and metastasis (malignant Spitz
of Spitz/Reed nevi. Clin Dermatol. 2002;20:259-62. nevus). Am J Surg Pathol. 1989;13:931-9.
Piccolo V, Moscarella E, Zalaudek I, et al. Analysis of clinical and Spitz S. Melanomas of childhood. Am J Pathol. 1948;24:591-609.
dermoscopic features in melanocytic lesions with special Weedon D, Little JH. Spindle and epithelioid cell nevi in children
emphasis on problematic lesions in children. Expert Rev Der and adults. A review of 211 cases of the Spitz nevus. Cancer.
matol. 2013;8:155-70. 1977;40:217-25.
6.7 BLUE NEVUS AND COMBINED NEVUS

Horacio A Cabo
The blue nevus (BN) is a melanocytic nevus that may be In the clinical aspect, the features of the BN prevail in
classified as common and cellular. Common BN is a nod the lesion. It may be similar to a BN or present a targetoid
ular lesion (<0.5 cm), bluish-gray or bluish-black. It usually form (combined targetoid nevus), which presents a blue
appears as a single lesion, and it may manifest in any central area and a light or dark brown coloration in the
tegument area, although it is more frequent in the back peripheral area of the lesion.
of hands and feet, the scalp, and mucosae. It habitually Due to the overlapping of lesions with different histo
appears in infancy, yet it can also manifest in adulthood. logy, on occasion CN is considered a melanoma simula
Cellular BN is a larger nodule (>0.5–3 cm), blue or tor. Histology depends on the type of nevi associated in the
black in color, which preferably locates in the sacrocoxal lesion.
area or in the buttocks (Fig. 6.91). Appears in infancy and The most frequent scenario is a common or cellular
manifests less frequently than the common BN. BN combined with a melanocytic nevus.
Some blue nevi are asymmetrical, in different shades
of blue, and may simulate a melanoma (Fig. 6.92).
Dermoscopic Criteria
For a correct diagnosis, it is very important to know the Blue Nevus
duration of the nevi if possible, since it generally appears It shows a homogeneous blue coloration with generally
in youth, as has already been pointed out. uniform pigmentation (Figs. 6.97 to 6.99).
Melanoma metastasis, tattoos, and radiotherapy This blue pigmentation looks different under polarized
marks may be mistaken with common new nevi, among and nonpolarized light dermoscopes (Figs. 6.100A and B).
others (Figs. 6.93 to 6.96). Sclerotic BN is a variant that presents a central
The combined nevus (CN) is a melanocytic nevus hypopigmented area (Fig. 6.101).
characterized by the association of a BN with a nevocel
lular nevus (dermal, compound or juncture) in the same Combined Nevus (Figs. 6.102 to 6.104)
lesion. On occasion, it is possible to observe a BN associ They may present a homogeneous blue coloration that
ated to a Spitz nevus. makes them indistinguishable from blue nevi.
Fig. 6.91: Blue cellular nevus (clinical view: arrow). Fig. 6.92: Asymmetric blue nevus.
A B
Figs. 6.93A and B: Melanoma metastasis.
Fig. 6.94: Melanoma metastasis—clinical view.
A B
Figs. 6.95A and B: Melanoma metastasis (blue nevus-like).
Fig. 6.96: Tattoo in the scar.
A B
C D
Figs. 6.97A to D
E Figs. 6.97A to E : Blue nevus.
Fig. 6.98: Blue nevus in the scalp. Fig. 6.99: Blue nevus in the sole.
A B
Figs. 6.100A and B: Blue nevus under polarized dermoscopy.
Fig. 6.101: Sclerotic blue nevus. Fig. 6.102: Combined nevus (intradermal nevus + blue nevus).
Fig. 6.103: Combined nevus (junction nevus + blue nevus). Fig. 6.104: Combined nevus.
There may also be combined nevi with two colors, a SUGGESTED READING
homogeneous blue, dark blue, or black central zone and Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas
a peripheral zone in different shades of brown with struc of Dermoscopy. Milán: EDRA Medical Publishing & New
tureless areas, globules, or pigment network. All these Media; 2000.
structures corresponding to the superficial component 2000.
(generally a nevocellular nevus) are invisible in the central Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina:
zone owing to a black or blue color that stems from the Ediciones Journal; 2012.
deep component of the lesion (BN). If the superficial com Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment
ponent were highly pigmented, the lesion would appear Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials
totally dark. (MOABT). New York: Elsevier Ltd; 2004.
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
tern Analysis. Austria: Facultas.wuv; 2011. American Academy of Dermatology; 1999.
Lallas A. Dermoscopy in general dermatology. Dermatol Clin. Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
2013;3:679-94. mented Skin Lesions. An Atlas Based on the Consensus Net
New Media; 2001.
Taylor & Francis; 2005. Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros copy. Germany: Blackwell Science; 1994.
copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of non-pig
Company; 1996. mented skin tumors. Boca Raton, FL: CRC Press; 2016.
6.8 RECURRENT NEVUS

Horacio A Cabo
The recurrent or persistent nevus (RN) constitutes the Reactive Pigmentation

recurrence of pigmentation that manifests after the It is most frequently seen after excisions followed by
incomplete excision of a nevus, generally compound or suture. The histologic scenario goes from hyperpigmen
intradermal. tation of the basal layer at one end, through lentiginous
Although most RN are secondary to an incomplete epidermal hyperplasia, to melanocytic hyperplasia, without
excision (shave excision), they can also appear after laser the presence of melanocytic nests.
surgery, radiotherapy, or nevus traumatism. The most fre •• Streaks or lines: It is possible to observe brown lines
quent site of appearance is the trunk. that may be:
Due to its clinical and dermoscopic features, it is –– Thin and radiated from the center to the peripheral
included among melanoma simulators. In relation to a area of the scar (Figs. 6.105 and 6.106).
differential diagnosis, it is fundamental to bear in mind the (On occasion we can see different variation of this: like
following parameters: thick homogeneous strip perpendicular to the scar central
•• History of previous excision axis or thin and parallel to the lesion central axis).
•• Histopathologic study, if it possible
•• Time span between appearance and recurrence True RN
–– Recurrent nevus: 4–10 months after excision Appear after trauma of a nevus or a shave, laser surgery
–– Melanoma: More than a year or radiotherapy of a nevus. Histopathology shows mela
•• Pigment location nocytic nests in the dermoepidermal and dermal junction.
–– RN: Scar pigmented
–– Melanoma: Pigmented lesions spread beyond the Dermoscopy (Figs. 6.107 to 6.114)
scar •• Globules with different sizes and distribution
The term RN comprises two scenarios: one is reactive •• Heterogeneous pigmentation
pigmentation of the scar; the other is nevus recurrence. •• Pigment network and lines: infrequent.
Fig. 6.105: Reactive pigmentation: streaks or lines thin and radiated Fig. 6.106: Reactive pigmentation: streaks or lines thin and radiated
from the center to the peripheral area of the scar. from the center to the peripheral area of the scar and the presence of
a recurrent nevus (arrow).
Fig. 6.107: Recurrent nevus: the pigmentation does not spread Fig. 6.108: Recurrent nevus: the pigmentation does not spread
beyond the scar; heterogeneous pigmentation. beyond the scar; different colors and parallel lines.
A B
Figs. 6.109A and B: Recurrent nevus: the pigmentation does not spread beyond the scar with pigment network and lines.
Fig. 6.110: Recurrent nevus: the pigmentation does not spread beyond
the scar with globules (white arrow) and streaks (red arrow).
Fig. 6.111: Recurrent nevus: the pigmentation does not spread beyond the
scar with globules (arrow).
A B
Figs. 6.112A and B: Recurrent nevus: the pigmentation does not spread beyond the scar with pigment network and lines in the center of the
lesion.
Fig. 6.113: Recurrent nevus: the pigmentation does not spread Fig. 6.114: Recurrent nevus: the pigmentation does not spread
beyond the scar with pigment network and lines. beyond the scar. Atypical vascular pattern with red areas (white arrow);
linear irregular vessels (red arrows); and brown globules (black arrow).
SUGGESTED READING Lallas A. Dermoscopy in general dermatology. Dermatol Clin.

2013;3:679-94.
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea
of Dermoscopy. Milán: EDRA Medical Publishing & New ciones Gráficas; 2009.
Media; 2000. Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
Blum A, Hofmann-Wellenhof R, Marghoob AA, et al. Recurrent Taylor & Francis; 2005.
melanocytic nevi and melanomas in dermoscopy: results of Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
a multicenter study of the International Dermoscopy Society. copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
JAMA Dermatol. 2014;150(2):138-45. Company; 1996.
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
Ediciones Journal; 2012. mented Skin Lesions. An atlas based on the consensus net
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Guide, 2nd edition. McGraw-Hill Education; 2015. New Media; 2001.
Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
(MOABT). New York: Elsevier Ltd; 2004. copy. Germany: Blackwell Science; 1994.
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
tern Analysis. Austria: Facultas.wuv; 2011. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
6.9 MELANOMA
6.9.1 Superficial Spreading Melanoma
Horacio A Cabo
Superficial spreading melanoma (SSM) is the most com •• Unspecific pattern: This is present in those lesions that
mon type of melanoma. Its incidence is slightly higher in cannot be classified within any of the previous pat
men than in women. It lies in areas with intermittent solar terns. In the presence of this pattern, it is essential to
exposure and preferably in the lower limbs of females and rule out the existence of a possible melanoma in all
the back of males. cases.
In recent years, the frequency of its appearance has
increased. It has a phase of radial growth that may be of Local SSM Patterns
variable but prolonged duration, until finally entering Almost all these methods evaluate the presence of the foll
the vertical invasive growth phase with the possibility of owing local dermoscopic features:
metastasis and of causing the death of the patient. •• Atypical pigment network
As it is widely known, the best treatment for melanoma •• Negative pigment network
is the early diagnosis since in the case of in situ forms, exci •• Irregular streaks
sion with adequate margins ensures a cure rate close to •• Irregular dots and globules
100%. Having said that, it is necessary to perform an early •• Blue-white veil
diagnosis in initial lesions to ensure a good therapeutic result. •• Regression structures with white or blue areas
•• Irregular pigmentation
Clinical examination is very good, but not highly effec
•• Irregular vascular pattern
tive in small lesions, where dermoscopy has increased
•• Shiny white structures
diagnostic accuracy by 30% and proved to have very high
When analyzing the different lesions we must consider
specificity (80%) and sensitivity (90%).
that:
In pattern analysis, which is the method most widely
•• The presence of a criterion is more important than its
used by experts, the procedure is to evaluate general patterns
absence, as none of these criteria is 100% specific for
and local patterns. melanoma.
•• Only one criterion is not enough to proceed to a mela
General Patterns for SSM
noma diagnosis.
•• Multicomponent pattern: Stems from the combination •• Some criteria are more important than others.
of three or more dermoscopic patterns in the same •• The absence of definite criteria leading to a dermo
lesion. It is the pattern most frequently associated with scopic diagnosis must suggest the possibility that the
the existence of melanoma, although it can also be lesion should correspond to a melanoma.
observed in other lesions such as Clark nevus, Spitz–
Reed nevus, and congenital nevus. Atypical Pigment Network (Figs. 6.115 to 6.118)
•• Atypical reticular pattern: The lesion is fundamentally A black, gray, or brown network with irregular mesh and
composed of a pigment reticule or atypical pigment wide lines.
network.
•• Atypical globular pattern: Composed of dots and glob Negative Pigment Network (Figs. 6.119 to 6.124)
ules with irregular shape, size, and distribution. It is a structure composed of a network of slightly pig
•• Peripheral streaks pattern (starburst pattern): It is char mented lines and dark openings, and provides a “nega
acterized by the presence of projections or lines adopting tive” image of the pigment reticule. At a histologic level,
a regular radial distribution along the periphery of the the pigmented openings are large nests of melanocytic
pigmented lesion, which is characteristic of Spitz– cells located in the dermal papillae, and the network lines
Reed nevus. However, some melanomas may present are elongated interpapillary processes. This structure
this pattern, especially in adults. appears in melanoma and Spitz nevi.
A B
C D
E F
Figs. 6.115A to F
G H
Figs. 6.115A to H: Melanoma in situ: atypical pigment network (arrow).
Fig. 6.116: Melanoma in situ: atypical reticular pattern with atypical Fig. 6.117: Melanoma in situ: atypical pigment network (red arrow);
pigment network. regression structures with blue areas (white arrow).
Fig. 6.118: Melanoma in situ: atypical pigment network (red arrow); Fig. 6.119: Superficial spreading melanoma B 0.3: atypical negative
regression structures with blue areas (white arrow) and white areas pigment network (red arrows).
(black arrow).
Fig. 6.120: Superficial spreading melanoma B 0.3: atypical negative Fig. 6.121: Superficial spreading melanoma: negative pigment network
pigment network in different areas of the lesion. (red arrow); atypical pigment network (black arrow).
Fig. 6.122: Superficial spreading melanoma: atypical negative pig Fig. 6.123: Superficial spreading melanoma: atypical negative
ment network (red arrow); irregular vascular pattern (black arrow); and pigment network (red arrow); irregular vascular pattern (black arrow);
regression structures with blue areas (white arrow). and irregular pigmentation (white arrow).
Fig. 6.124: Superficial spreading melanoma (B 0.86): atypical negative

pigment network (arrow).
Irregular Streaks (Irregular Projections) Regression Structures with White or Blue

(Figs. 6.125 to 6.129, 6.134 and 6.135) Areas (Figs. 6.141 to 6.144)
There are two types of lines or streaks: pseudopods and Blue and white areas are considered together, reflecting
radial or radiated projections. The former have a bulbous the two main morphological aspects of regression: fibrosis
digit-formed appearance, while the latter are fine radiated and melanosis (melanofagia).
lines. Clinically, they correspond to the flat part of the lesion.
Branching and pseudopods are considered as only one In the case of large regression areas, it is necessary to rule
criterion. Both correlate histologically to nests of melano out a melanoma.
cytes convergent in the dermoepidermal junction.
Irregular Pigmentation (Figs. 6.145 to 6.147)
Irregular Dots and Globules (Figs. 6.130 to 6.135) These areas correspond, inside a melanocytic lesion, to
The presence of dots and globules of different size and areas within which it is impossible to distinguish struc
color distributed irregularly over the melanocytic lesion tures. They may be either hyperpigmented brown, gray,
may suggest malignancy. or black areas, or areas of hypopigmentation. The distri
bution of these structures is very important, since when
Blue-white Veil (Figs. 6.136 to 6.140) localized irregularly and focally, they are more character
This is the blue-grey or blue-white (blue-whitish) con istic of a malignant lesion. Asymmetric hyperpigmented
fluent diffuse pigmentation, with absence of structures eccentric areas are more frequently associated to mela
within. noma than hypopigmented ones.
It is an important parameter; it is one of the most spe
cific melanoma parameters; however, it may also be found Irregular Vascular Pattern (Figs. 6.148A to D)
in fusocelular nevi or combined lesions. In the hypopigmented areas of a melanoma or in hypome
From a clinical point of view, it may correspond to a lanotic melanomas, it is possible to observe vessels with
raised area of the lesion. Histologically, it corresponds to the following features:
the presence of large confluent nests of highly pigmented •• Dotted vessels with irregular distribution
tumorous cells, in the superficial dermis, which appear •• Lineal vessels with irregular shape and distribution
veiled due to the overlapping of compact orthokeratosis •• Pink-whitish areas
with more or less acanthosis and hypergranulosis. •• Vessels within regression areas.
Fig. 6.125: Superficial spreading melanoma: irregular streaks (red Fig. 6.126: Superficial spreading melanoma: irregular streaks (arrows).
arrows); shiny white structures (white arrow).
Fig. 6.127: Superficial spreading melanoma (B 0.3): irregular streaks Fig. 6.128: Superficial spreading melanoma (B 0.5): irregular streaks
(arrows). (red arrow); negative pigment network (white arrow); and irregular
dots and globules (white circles).
Fig. 6.129: Superficial spreading melanoma: irregular dots and Fig. 6.130: Superficial spreading melanoma: irregular dots and glo
globules (red arrows); irregular streaks (black arrow); and negative bules (red arrows); regression structures with blue areas (white arrow).
pigment network (white arrow).
Fig. 6.131: Superficial spreading melanoma: irregular dots and glo Fig. 6.132: Superficial spreading melanoma: irregular dots and
bules (arrows). globules (white circle); shiny white structures (white arrow).
Fig. 6.133: Superficial spreading melanoma: irregular dots and glo Fig. 6.134: Superficial spreading melanoma: irregular dots and glo
bules (white circle); blue-white veil (red arrows); and negative pigment bules (white circle); irregular streaks (red arrows).
network (white arrow).
Fig. 6.135: Superficial spreading melanoma (B 0.4): irregular dots and Fig. 6.136: Superficial spreading melanoma B 0.7: blue-white veil
globules (white circle); irregular streaks (red arrows); negative pigment (arrow).
network (black arrow); and regression (white arrow).
Fig. 6.137: Superficial spreading melanoma B 0.91: blue-white veil Fig. 6.138: Superficial spreading melanoma B 0.6: blue-white veil and
(white circle); irregular streaks (white arrow). shiny white structures (white circle).
Fig. 6.139: Blue-white veil (white circle).
A B
Figs. 6.140A and B: Superficial spreading melanoma B 0.9: blue-white veil (white circles).
Fig. 6.141: Superficial spreading melanoma: regression structures with Fig. 6.142: Superficial spreading melanoma: regression structures with
white and blue areas (white circle). white and blue areas (white circle).
A B
Figs. 6.143A and B: Melanoma in situ: regression structures with white and blue areas (white circle).
Fig. 6.144: Superficial spreading melanoma B 0.3: regression structures Fig. 6.145: Superficial spreading melanoma B 0.8: irregular pigmentation
with white and blue areas (white circle). (white arrow).
Fig. 6.146: Superficial spreading melanoma B 1.5: irregular pigmentation Fig. 6.147: Superficial spreading melanoma: irregular pigmentation
(arrow). (arrow).
A B
C D
Figs. 6.148A to D: Irregular vascular pattern (white circles).
Shiny White Areas (Figs. 6.149 to 6.151) cutaneous surface, the orientation of the crystalline struc
Shiny white streaks are not visible with the naked eye or tures changes owing to the angular dependence of the
with the nonpolarized dermoscope. They can be seen in polarized light, reflecting the nonrandomized distribution
lesions with heightened collagen (melanoma, dermatofi of the collagen fibers in the dermis.
broma, scars, and basal cell carcinoma). Collagen streaks
are birefringent and this causes a fast randomization of the
Conclusion
polarized light. The knowledge of these structures allows the dermoscopic
It is a dynamic polarized dermoscopy since by rotat diagnosis of SSM with a diagnostic accuracy index higher
ing the dermoscope while keeping it in contact with the than under clinical examination.
Fig. 6.149: Superficial spreading melanoma B 1.2: shiny white structures Fig. 6.150: Superficial spreading melanoma: shiny white structures
(white circle). (white circle).
Fig. 6.151: Superficial spreading melanoma B 1.1: shiny white structures

(white circle).

Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Menzies S, Crotty K, Ingvar C, et al. An atlas of surface micros
of Dermoscopy. Milán: EDRA Medical Publishing & New copy of pigmented skin lesions. Sydney: McGraw-Hill Book
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; Pizzichetta M, Talamini R, Marghoob AA, et al. Negative pigment
2000. network: an additional dermoscopic feature for the diagnosis
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: of melanoma. J Am Acad Dermatol. 2013;68:552-9.
Ediciones Journal; 2012. Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment American Academy of Dermatology; 1999.
Guide, 2nd edition. New York: McGraw-Hill Education; Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
2015.
New Media; 2001.
(MOABT). New York: Elsevier Ltd; 2004. Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat copy. Germany: Blackwell Science; 1994.
tern Analysis. Austria: Facultas.wuv; 2011. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of non-
Lallas A. Dermoscopy in general dermatology. Dermatol Clin. pigmented skin tumors. Boca Raton, FL: CRC Press; 2016.
2013;3:679-94. Zalaudek I, Kittler H, Hofmann-Wellenhof R, et al. “White’’ net
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea work in Spitz nevi and early melanomas lacking significant
ciones Gráficas; 2009. pigmentation. J Am Acad Dermatol. 2013;69:56-60.
6.9.2 Nodular Melanoma

Horacio A Cabo
The name nodular melanoma (NM) is given to an inva –– The characteristic brown or black color may show
sive melanoma of vertical growth without a radial growth red, white, and/or blue foci
phase. Nodular melanoma must be distinguished from –– On occasion it is amelanotic or hypomelanotic
the nodular component that may develop in a superficial •• Dermoscopic characteristics (Figs. 6.153 to 6.156): These
spreading melanoma (Fig. 6.152). Nodular melanoma lesions do not usually show criteria related to radial
represents 14% of invasive melanoma and 56% of thick growth and the pagetoid spreading of the tumor (lines
melanoma (>3 mm). or streaks, black dots/globules, and multiple gray
Nodular melanoma has the highest death rate of all dots), neither those observed in fine melanomas (pig
ment network) and in early regression stages [white
melanoma, despite being less frequent than spreading
areas (fibrosis) and blue areas (melanosis)], and mul
superficial melanoma (SSM), which causes the most
tiple blue gray dots.
deaths of all melanoma due to its high frequency.
It is therefore very important to bear in mind that for Dermoscopy characteristics of Nodular Melanoma
any raised lesion we should never proceed to a short- or • Absence of radial growth and pagetoid spreading criteria
long-term follow-up when suspecting an atypical lesion, –– Lines and streaks
since if it were a case of NM the prognosis might be much –– Irregular dots and globules
• Absence of criteria for fine melanoma
worse. If in doubt it is better to perform a biopsy.
–– Atypical pigment network
Nodular melanomas have clinical and dermoscopic • Absence of regression criteria
features different from those of the other types of melanoma. –– White or blue areas with multiple blue-gray dots
Clinical Characteristics Neither can we find dermoscopic criteria for special

locations (such as face, palms, and soles) owing to the
It usually appears as a fast growing nodule, occasionally destruction of specific anatomical structures during the
ulcerated, with asymmetric pigmentation pattern, yet less growth of thick melanoma.
pronounced than in the case of more superficial forms.
The characteristic brown or black color may contain Dermoscopy characteristics of Nodular Melanoma
red, white, and/or blue foci. On occasion, the pigment is • Absence of dermoscopic criteria for special locations (such as
face, palms and soles) owing to the destruction of anatomical
scarce or even lacking, and it is possible to see skin-color structures specific during the growth of thick melanoma.
lesions (amelanotic melanoma), which may hinder the
diagnosis. Dermoscopic examination of NM usually shows ordi
In order to achieve a diagnosis, it is necessary to trace nary thick melanoma criteria, such as the presence of mul
additional signs in the patient’s record, such as changes in tiple colors (black, light brown, dark brown, blue, gray, red,
and white), blue-white veil (blue-white or white-grayish
size, color, and shape of the lesion, or any ulceration sign
diffuse confluent pigmentation), and atypical vascular
or spontaneous bleeding.
pattern
Nodular melanomas are fast growing melanomas and
their onset is hidden from the eye because they start under Dermoscopy characteristics of Nodular Melanoma
the skin. Thick melanoma criteria
They generally appear in patients with few nevi and it • Blue-white veil
is thought that solar exposure does not play a major role in • Multiple colors (5–6)
• Atypical vascular pattern
their development.
–– Irregularly distributed dots
•• Clinical features: –– Irregular lineal vessels
–– Fast growing nodule –– Milky-red globules
–– Sometimes ulcerated • Blue-black rule: The presence of blue and black color in the same
lesion.
–– With symmetric or asymmetrical pigment pattern
Fig. 6.152: Thick spreading superficial melanoma B 1.8 with irregular

streaks, blue-white veil, and irregular dots and globules (white oval).
A B
C D
Figs. 6.153A to D: Nodular melanoma: blue-white veil and multiple colors.
Fig. 6.154: Nodular melanoma: blue-white veil and multiple colors and
atypical vascular pattern with irregularly distributed globules (arrow).
A B
Figs. 6.155A and B: Nodular melanoma: blue-white veil and multiple colors and atypical vascular pattern with irregularly lineal vessels.
Fig. 6.156: Nodular melanoma: blue-white veil and atypical vascular

pattern with irregularly lineal vessels and milky-red areas.
SUGGESTED READING Mar V, Roberts H, Wolfe R, et al. Nodular melanoma: a distinct

clinical entity and the largest contributor to melanoma deaths
Argenziano, Longo C, Cameron A, et al. Blue-black rule: a sim in Victoria, Australia. J Am Acad Dermatol. 2013;68:568-75.
ple dermoscopic clue to recognize pigmented nodular mela Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
noma. BJD. 2011;165:1251-5. Taylor & Francis; 2005.
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
Menzies SW, Moloney FJ, Byth K, et al Dermoscopic evalua
2000.
tion of nodular melanoma. JAMA Dermatol. 2013; 149(6):
699-709.
(MOABT). New York: Elsevier Ltd; 2004. American Academy of Dermatology; 1999.
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
Guide, 2nd edition. New York: McGraw-Hill Education; 2015. mented Skin Lesions. An Atlas Based on the Consensus Net
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
tern Analysis. Austria: Facultas.wuv; 2011. New Media; 2001.
Lallas A. Dermoscopy in general dermatology. Dermatol Clin. Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
2013;3:679-94. copy. Germany: Blackwell Science; 1994.
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
ciones Gráficas; 2009. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
6.9.3 Lentigo Maligna Melanoma

Horacio A Cabo
Dermoscopy has decreased the number of cutaneous Lentigo maligna progression model: (Figs. 6.158A and B)
biopsies. However, in the case of the face it has increased Annular–granular pattern
them. This is due to the fact that with dermoscopy it is
Annular pattern (initial criteria in the development
possible to distinguish the subtle changes and structures
of LM)
leading to an early diagnosis, of high importance in lentigo
•• Gray or black pigmentation of the follicular openings
maligna melanoma (LMM). Lentigo maligna melanoma
•• Asymmetric pigmentation of the follicular openings
appears in skin that has been chronically exposed to light,
(also known as gray circles)
usually on the face and in middle-aged and elderly people.
•• Circle within a circle (gray dots within the follicular
The face has a particular anatomic feature: in adult
openings)
facial skin, the rete ridge is flattened or simply absent,
which means that the pigment network is not observable Granular pattern around the hair follicles
(Fig. 6.157). •• Gray dots
The hair follicles, as well as the sebaceous and sweat •• Gray globules
glands, have no pigment and it is possible to observe a •• Lines around the follicles
pseudonetwork made up of a thick mesh resulting from With greater progression:
the skin color and the white openings, which correspond •• Rhomboidal structures (the lines become longer and
to the follicular openings, since these areas lack melanin cross each other)
pigment. This pseudonetwork is present in melanocytic •• Blue-gray or black homogeneous areas with or with
and nonmelanocytic lesions on the face. Therefore, in the out invasion of the follicular openings
case of the face it is not possible to differentiate between •• Whitish and pink structures
melanocytic and nonmelanocytic lesions by the pseudo
network, which makes it necessary to use other criteria. Dermoscopic Features (Figs. 6.159 to 6.174)
On the face, the most important differential diagnosis Classic Criteria
is between lentigo maligna (LM), solar lentigo (flat seb
Blue-gray color: Sometimes this color is the only clue to
orrheic keratosis), pigmented actinic keratosis, and liken
suspect a malignant lentigo.
planus-like keratosis. Blue, gray or black pigmented and asymmetrically pig-
Dermoscopy of pigmented lesions on the face mented follicular openings: are dark brown or black in
•• General considerations color, which indicates the irregular proliferation of atyp
–– Classical pigmented network ical melanocytes within the follicles. In LM (melanoma in
▪▪ Infrequent on the face situ) and in LMM (invasive melanoma), if the follicles are
▪▪ Flat rete ridge close together, it is possible to perceive a second pseudo
–– Pigmented pseudonetwork network characterized by a thin mesh, as opposed to the
▪▪ Frequent on the face pseudonetwork that depends on location and presents
▪▪ Hair follicle openings and sweat glands lack a thick mesh. These grid-like structures are pseudonet
pigment works, since they do not arise from the pigmentation of
▪▪ Present in melanocytic and nonmelanocytic the crests or ridges of the rete ridges but from the follicular
lesions openings in pigmented facial skin.
▪▪ Other criteria are necessary to differentiate Two concentric circles (circle within a circle): This new
these lesions from one another. criteria is highly useful and its significance, statistically
Fig. 6.157: The face has a particular anatomic feature: in adult facial
skin, the rete ridge is flattened or simply absent, which means that the
pigment network is not observable.
A B
Figs. 6.158A and B: Lentigo maligna progression model.
Fig. 6.159: Lentigo maligna: blue-gray color (arrows).

A B
C D
Figs. 6.160A to D: Lentigo maligna: blue-gray pigmented follicular openings (black arrows); asymmetric pigmentation of the follicular openings
(red arrows); circle within a circle (white arrows).
Fig. 6.161: Lentigo maligna: asymmetric pigmentation of the folli Fig. 6.162: Lentigo maligna: asymmetric pigmentation of the follicular
cular openings (red arrows); circle within a circle (white arrows). openings (arrows).
Fig. 6.163: Lentigo maligna: blue-gray pigmented follicular openings Fig. 6.164: Lentigo maligna: blue-gray pigmented and asymmetric
(black arrow); asymmetric pigmentation of the follicular openings pigmentation of the follicular openings.
(red arrows).
Fig. 6.165: Lentigo maligna: slate-gray dots around the follicular Fig. 6.166: Lentigo maligna: circle within a circle (arrows).
openings (yellow arrow); asymmetric pigmentation of the follicular
openings (red arrow).
Fig. 6.167: Lentigo maligna: slate-grey dots around the follicular Fig. 6.168: Lentigo maligna: blue-gray pigmented follicular openings
openings (red circle); rhomboidal structures (white circle). (black arrow); asymmetric pigmentation of the follicular openings
(red arrow); circle within a circle (white arrow); rhomboidal structures
(white circle).
Fig. 6.169: Lentigo maligna: rhomboidal structures (white circle). Fig. 6.170: Lentigo maligna: rhomboidal structures (white circle);
slate-gray dots around the follicular openings (yellow circle).
Fig. 6.171: Lentigo maligna melanoma: rhomboidal structures (white Fig. 6.172: Lentigo maligna melanoma: rhomboidal structures (white
circle); slate-gray dots around the follicular openings (yellow circle); circle); homogeneous blue-gray areas with the hair follicles obliterated
homogeneous blue-gray areas with the hair follicles spared (red circle). (yellow circle); asymmetric pigmentation of the follicular openings
(red arrow); circle within a circle (white arrow).
Fig. 6.173: Lentigo maligna melanoma: circle within a circle (white circles); Fig. 6.174: Lentigo maligna melanoma: homogeneous blue-gray
homogeneous blue-gray areas with the hair follicles obliterated (white areas with the hair follicles obliterated (arrow).
arrow) or spared (yellow arrow); rhomboidal structures (red arrow).
undetermined yet, could be similar to that of the asym •• Increased density of the vascular network
metric pigmentation of the follicular openings. •• Red rhomboidal structures
Slate gray dots around the follicular openings: It is an There are many lesions that may resemble the initial
early sign of LM and it is the beginning of granular–annu changes observed in malignant lentigo. In teenagers, mela
lar pattern. nocytic nevi may present slate-gray lines and dots. Liken
Rhomboidal structures: At a later stage, it is possible to planus-like keratosis and irritated form of seborrheic ker
detect dark brown or black lines or short streaks, highly
atosis may also present gray lines and dots. In pigmented
specific around the follicles.
actinic keratosis, the main melanin location is the macro
Homogeneous blue-gray areas with the hair follicles
phages of the upper dermis, just as it happens in incipient
spared or obliterated.
malignant lentigo. Asymmetric follicular openings tend to
New Criteria (Figs. 6.175 to 6.178) be absent. There are some other indicators of pigmented
•• Darkening at dermoscopic examination actinic keratosis, including the habitual presence of mul
•• Target-like pattern tiple lesions and its rough surface. It is possible that the
Fig. 6.175: Darkening at dermoscopic examination. Fig. 6.176: Target-like pattern.
Fig. 6.177: Increased density of the vascular network. Fig. 6.178: Red rhomboidal structures (white oval).
differentiation may result microscopically difficult, since Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea
sun-damaged skin usually presents melanocytic atypia. If ciones Gráficas; 2009.
in doubt, a biopsy must be performed. All these simulators
and malignant lentigo may present asymmetric follicular Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
openings. This crucial fact is highly frequent in malignant copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
lentigo and infrequent in the other lesions. Company; 1996.
Pralong P, Bathelier E, Dalle S, et al. Dermoscopy of lentigo maligna
melanoma: report of 125 cases. BJD. 2012;167:280-7.
SUGGESTED READING Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas American Academy of Dermatology; 1999.
of Dermoscopy. Milán: EDRA Medical Publishing & New Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
Media; 2000. mented Skin Lesions. An Atlas Based on the Consensus Net
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
2000. New Media; 2001.
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: Stolz W, Braun-Falco O, Bilek P, et al. Color atlas of Dermatos
Ediciones Journal; 2012. copy. Germany: Blackwell Science; 1994.
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment Tiodorovic-Zivkovic D, Argenziano G, Lallas A, et al. Age, gen
Guide, 2nd edition. New York: McGraw-Hill Education; 2015. der, and topography influence the clinical and dermo
Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials scopic appearance of lentigo maligna. J Am Acad Dermatol.
(MOABT). New York: Elsevier Ltd; 2004. 2015;72:801-8.
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Tschandl P, Rosendahl C, Kittler H. Dermoscopy of flat pig
tern Analysis. Austria: Facultas.wuv; 2011. mented facial lesion. JEADV. 2015;29:120-7.
2013;3:679-94. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
6.9.4 Acral Melanoma

Horacio A Cabo
Acral melanoma represents 10% of all human melanomas

and it is most frequently observed in Asian and black
populations. In the past it was believed that melanocytic
lesions in acral areas were more dangerous since friction
might turn them malignant. For years, nevi were routinely
excised under the misconception that they could become
melanoma.
Besides, there were mistakes in the interpretation of
these lesions, which delayed diagnosis with a worse prog
nosis and survival prospects, many times also due to inad
equate treatment.
Dermoscopy is an extremely useful technique to con
firm a suspected melanoma in locations and to distinguish
benign lesions, which prevents many unnecessary biop
sies. Fig. 6.179: Scheme of the skin anatomy in palms and soles.
This chapter specifically refers to localized melanoma
in the acral zone, in the volar skin of this particular ana
tomical area. Acral Melanoma Dermoscopic
Thus, it is necessary to interpret the cutaneous ana Patterns (Figs. 6.180 to 6.192)
tomical structure, which differs from that observed in the •• Parallel ridge pattern: It has 99% specificity and 86.4%
back of hands and feet. In these cases, the main surface sensitivity. It presents a brown, dark brown, or black
characteristic consists in the presence of dermatoglyphics pigmentation located predominantly on the ridge. It
of furrows and ridges, which are particular to each individ correlates to the in situ component of acral lentiginous
ual by means of a genetic combination. The skin anatomy melanoma and therefore may be observed in early
shows specific features due to the heightened depth of its lesions or peripheral areas of invasive melanoma.
corneal layer, the absence of hair follicles, the presence of Exceptionally, this pigmentation has been described
eccrine glands, and a repetition of crista intermedia and in some benign melanocytic lesion. (Ethnic pigmentation,
crista limitans (Fig. 6.179). in Peutz-Jeghers syndrome and subcorneal hemorrhages).
Characteristically, eccrine glands are located in the •• Diffuse pigmentation with varying coloration
crista intermedia; therefore, their eccrine ducts lead to the •• Irregular and peripheral globules/dots
surface of the ridge (crista superficials). •• Abrupt end of pigmentation at the periphery of the lesion.
In the case of benign melanocytic lesions, the nests of In general, the behavior is:
nevic cells tend to lie fundamentally in the sulci or furrows. •• Typical benign patterns (see Chapter 9, part 2): no fol
This phenomenon, of unknown origin, gives rise to der low-up
moscopic patterns described in another chapter of this •• Parallel ridge pattern: biopsy in order to rule out mel
book: parallel furrow-pattern, lattice-like pattern, fibrillar anoma
pattern. Benign acral lesions also present other charac •• Atypical pattern without the presence of parallel ridge
teristic patterns (globular, homogeneous, and reticular) pattern: follow-up or excision. In order to excise, the
and finally, an atypical pattern defining those lesions that following points must be taken into account:
cannot be classified in the same manner as the previous –– Size >7 mm, age, history, recent alterations, and
ones. In the case of localized lesions in the transition area any other data suspicious of melanoma.
between volar skin and back of hands and feet (Wallace Recently, it developed a new algorithm named BRAFF
line), a transition pattern can be observed combining Checklist that significantly improves the diagnostic accu
benign parallel patterns and pigmented reticule. racy of dermoscopy for the diagnosis of acral melanoma.
Fig. 6.180:Acral nevus: parallel furrow-pattern. Fig. 6.181: Acral nevus: lattice-like pattern.
A B
Figs. 6.182A and B: (A) Acral melanoma—clinical view. (B) Acral melanoma: parallel ridge pattern (arrows); diffuse pigmentation with varying
coloration.
A B
Figs. 6.183A and B
Figs. 6.183A to C: (A) Acral melanoma—clinical view. (B) Acral melanoma:

diffuse pigmentation with varying coloration with irregular parallel arran
gement. (C) Acral melanoma: irregular pattern of the overlying lines in
their thickness, color, and spacing (white arrow); parallel ridge pattern
(red arrows).
C
A B
Figs. 6.184A and B: (A) Acral melanoma—clinical view. (B) Acral melanoma—parallel ridge pattern (arrows); diffuse pigmentation with varying
coloration.
A B
Figs. 6.185A and B: (A) Acral melanoma—clinical view. (B) Acral melanoma—parallel ridge pattern (arrows); diffuse pigmentation with varying
coloration.
Fig. 6.186: Acral melanoma—parallel ridge pattern (arrows); diffuse Fig. 6.187: Acral melanoma—parallel ridge pattern (arrows); diffuse
pigmentation with varying coloration. pigmentation with varying coloration.
Fig. 6.188: Acral melanoma—parallel ridge pattern (arrows); diffuse Fig. 6.189: Acral melanoma—parallel ridge pattern (arrows); diffuse
pigmentation with varying coloration. pigmentation with varying coloration.
Fig. 6.190: Acral melanoma—parallel ridge pattern (arrows); diffuse pig

mentation with varying coloration; irregular and peripheral globules/
dots (circle).
Fig. 6.191: Acral melanoma—parallel ridge pattern (arrows); diffuse Fig. 6.192: Acral melanoma—parallel ridge pattern; diffuse pigmen
pigmentation with varying coloration. tation with varying coloration.
BRAAFF checklist includes six variables—four positive Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials
and two negative. (MOABT). New York: Elsevier Ltd; 2004.
Positive predictors: tern Analysis. Austria: Facultas.wuv; 2011.
•• Blotches (irregulars) Lallas A, Kyrgidis A, Koga H, et al. The BRAAFF checklist: a new
•• Ridge pattern dermoscopic algorithm for diagnosing acral melanoma. Br J
Dermatol. 2015;173:1041-9.
•• Asymmetry of structures
•• Asymmetry of colors 2013;3:679-94.
Negative predictors: Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea
•• Furrow pattern
•• Fibrillar pattern Taylor & Francis; 2005.
SUGGESTED READING Company; 1996.
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
of Dermoscopy. Milán: EDRA Medical Publishing & New American Academy of Dermatology; 1999.
Media; 2000. Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; mented Skin Lesions. An Atlas Based on the Consensus Net
2000. Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina: New Media; 2001.
Ediciones Journal; 2012. Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment copy. Germany: Blackwell Science; 1994.
Guide, 2nd edition. New York: McGraw-Hill Education; Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
2015. Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016
6.9.5 Amelanotic Melanoma

Horacio A Cabo
A low percentage of cutaneous melanomas (>2%) show no •• Pigment traces

pigmentation under clinical examination (amelanotic). •• Vascular structures within the amelanotic/hypome
These are frequently metastatic melanomas. Many amela lanotic area:
notic primary cutaneous melanomas are nodular. In these –– Dotted vessels: These are indicative of melanocytic
cases, we do not use the clinical ABCD rule, but the clin tumors, with 90% positive predictive value (i.e.
ical EFG rule instead (elevated—firm—growing). This is probability) that a lesion presenting such vessels
generally a clinical issue rather than a histologic one, since should be melanocytic.
histologically it is usual to find melanin evidence. Thus, –– Irregular lineal vessels: They have 68% predictive
the diagnosis difficulty lies on the clinical dermatologist, value in melanoma diagnosis. They are a signifi
not the pathologist. cant feature in thin melanomas (> 1 mm Breslow
In cutaneous primary melanomas, clinical classifica thickness) compared to benign melanocytic lesi
tion does not exactly correlate with dermoscopic observa
ons, with 19% sensitivity and 199% specificity in
tion, as this technique permits the observation of colors
melanoma diagnosis.
and structures not visible with the naked eye.
–– Pink areas or globules (milky-red areas) (Figs. 6.199B
The dermoscopic classification of amelanotic mela
and 6.200B): They present a blurred border as
nomas is different since some of them present pigmen
opposed to the highly demarcated and well-circum
tation traces and it is preferable to call them amelanotic/
scribed borders of the hemangioma red lacunes. The
hypomelanotic.
milky-red globules and milky-red areas (larger in
Dermoscopic Classification of size) have a 78% prognostic predictive value in the
Amelanotic/Hypomelanotic melanoma diagnosis.
Melanoma (Figs. 6.193 to 6.209) –– Hairpin vessels (Figs. 6.194C and 6.201B): These
•• Amelanotic melanoma: No color derived from melanin are common in seborrheic keratosis but can also
pigment (light brown, dark brown, blue, gray, or black) be found in amelanotic melanoma, particularly in
is observed under the dermoscopic examination. the thick one.
•• Hypopigmented melanoma: –– Halo melanoma: Asymmetrical white halo in a
–– Lightly pigmented melanoma: It presents light lesion with dermoscopic features of melanoma.
brown, pale blue, or pale gray pigmentation that may Recently, a diagnostic algorithms have been devel
cover >25% of the total surface area, but no evidence oped based on conclusions from the study of amelanotic
of dark brown, deep blue, or black coloration. and hypomelanotic melanoma to help detect this type of
–– Partially pigmented melanoma: Under dermosco melanomas.
pic examination, the melanin pigment is observable
in <25% of the total tumor surface. In highly pigmen Diagnostic Algorithms of Amelanotic
ted areas of the partially pigmented melanoma, it Melanoma
is possible to find other classical pigmented der •• Negative characteristic (must not be present)
moscopic features of melanoma. –– More than three milia-like pseudocysts
•• Melanoma with regression: When the amelanosis in a •• Positive characteristics (at least one must be present)
melanoma is the result of regression, it is possible to –– Brown dots and globules with irregular size and
visualize the classical dermoscopic features of scar- distribution
like depigmentation [white areas (fibrosis) and blue –– Multiple blue-gray dots
areas (melanosis)]. –– Blue-white veil
–– Irregular depigmentation
Dermoscopic Features of –– More than one shade of pink
Amelanotic/Hypomelanotic –– Predominantly central vessels
Under dermoscopic examination it is possible to observe: –– Dotted vessels and irregular vessels.
A B
Figs. 6.193A and B: Hypomelanotic melanoma in situ (partially pigmented melanoma): (A) Clinical view. (B) Light brown reticular pigmentation
(white circle); dotted vessels (red circle); irregular lineal vessels (red arrows).
A B
Figs. 6.194A to C: Hypomelanotic melanoma in situ (partially pig

mented melanoma): (A) Clinical view. (B) Light brown pigmentation
(white circle); dotted and irregular lineal vessels in the area without
pigmentation. (C) Close-up Figure 6.194B—dotted vessels (red arrow);
irregular lineal vessels (black arrow); hairpin vessels (white arrow).
C
A B
Figs. 6.195A and B: Hypomelanotic melanoma in situ (partially pigmented melanoma): (A) Clinical view. (B) Light brown pigmentation (white
circle); dotted and irregular lineal vessels in the area without pigmentation.
A B
(white circle); dotted and irregular lineal vessels in the area without pigmentation.
A B
Figs. 6.197A and B: Hypomelanotic melanoma in situ (partially pigmented melanoma): (A) Clinical view. (B) Light brown pigmentation and
irregular lineal vessels in the area without pigmentation (white circle). This image was taken with nonpolarized dermoscopy.
A B
Figs. 6.198A to C: Hypomelanotic melanoma in situ (partially pigmented

melanoma): (A) Clinical view. (B) Clinical view (close-up). (C) Light brown
C reticular pigmentation (white circle); irregular lineal vessels (red arrows).
A B
(white circle); irregular lineal vessels (red arrow); pink areas (milky-red areas) (black arrow).
A B
Figs. 6.200A and B: (A) Hypomelanotic melanoma in situ (lightly pigmented melanoma) clinical view (white arrow). (B) Hypomelanotic
melanoma—superficial spreading melanoma B 0.3 mm (lightly pigmented melanoma) light brown reticular pigmentation (white circle); irregular
lineal vessels (red arrow); pink areas (milky-red areas) (black arrow).
A B
Figs. 6.201A and B: (A) Hypomelanotic melanoma in situ (lightly pigmented melanoma) clinical view. (B) Hypomelanotic melanoma—superficial
spreading melanoma B 0.3 mm (lightly pigmented melanoma) light brown reticular pigmentation (white circle); irregular lineal vessels (red
arrow); hairpin vessels (black arrow); dotted vessels (red circle).
A B
Figs. 6.202A and B: (A) Hypomelanotic melanoma in situ (lightly pigmented melanoma) clinical view (black arrow). (B) Hypomelanotic
melanoma—superficial spreading melanoma B 0.3 mm (lightly pigmented melanoma) light brown reticular pigmentation (white circle); irregular
lineal vessels (red arrow).
Fig. 6.203: Melanoma in situ with a large area of regression (white circle). Fig. 6.204: Melanoma in situ with a large area of regression (white circle).
Fig. 6.205: Melanoma in situ with a large area of regression (white circle). Fig. 6.206: Melanoma in situ with a large area of regression (white circle).
Fig. 6.207: Superficial spreading melanoma with a large area of regression Fig. 6.208: Amelanotic nodular melanoma. Irregular lineal vessels (white
(white circle). arrow); pink areas (milky-red areas) (black arrow).
A B
Figs. 6.209A and B: Superficial spreading melanoma B 0.6 with white halo: (A) Clinical view (white circle); (B) dermoscopy view.
SUGGESTED READING Menzies SW, Kreusch J, Byth K, et al. Dermoscopic evaluation of

amelanotic and hypomelanotic melanoma. Arch Dermatol.
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas 2008;144(9):1120-7.
of Dermoscopy. Milán: EDRA Medical Publishing & New Pizzichetta MA, Talamini R, Stanganelli I, et al. Amelanotic/
Media; 2000. hypomelanotic melanoma: clinical and dermoscopic fea
tures. Br J Dermatol. 2004;150:1117-24.
Guide, 2nd edition. McGraw-Hill Education; 2015
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
tern Analysis. Austria: Facultas.wuv; 2011. New Media; 2001.
Lallas A. Dermoscopy in general dermatology. Dermatol Clin. Stojkovic-Filipovic J, Kittler H. Dermatoscopy of amelanotic
2013;3:679-94. and hypomelanotic melanoma. JDDG. 2014;12(6):467-72.
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea Stolz W, Braun-Falco O, Bilek P, et al. Color atlas of Dermatos
ciones Gráficas; 2009. copy. Germany: Blackwell Science; 1994.
Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London: Zalaudek I, Argenziano G, Kerl H, et al. Amelanotic/hyp
Taylor & Francis; 2005. omelanotic melanoma: is dermatoscopy useful for diag
Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros nosis? J Deuts Dermatol Ges. 2003;1:369-73.
copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
Company; 1996. pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
6.9.6 Dermoscopy Approach in Patients with Multiple Nevi

Horacio A Cabo
At present it is very common to receive patients who want which are mostly atypical N and may be confused with
to have their nevi (N) checked. On occasion we see patients M, even under dermoscopic examination.
who are deeply concerned about their N, but under exam •• This is the reason for the improved specificity, whereas
ination are found to have almost none. They are low-risk the sensitivity shows a more moderate improvement
patients and we generally check them less frequently. (Figs. 6.215 to 6.218).
Since it may happen that a patient with few or without any The fact is that the decrease in the number of biop
N could present a melanoma (M) we check them anyway sies, the fall in the benign/malignant relationship, and
(Figs. 6.210 and 6.211). the improvement in sensitivity and specificity have been
But the case that most concerns dermatologists is that reached by studying individual lesions, but not in the
of patients with a high M risk. Among these risks, present context of patients with multiple N (Fig. 6.219).
ing multiple N is a very important factor (Figs. 6.212 and
6.213). What Can We Do? (Figs. 6.220 to 6.223)
In relation to M detection in these patients, dermos It is also useless in the case of these patients to perform
copy (Fig. 6.214): multiple excisions, since the great majority of the excised
•• Has been proven to reduce the number of biopsies and lesions are N and not M. The clinical ABCD rule is not
unnecessary excisions by 40% depending on the expe helpful in small lesions. And finally, just dermoscopy is
rience of the observer. not enough because many benign lesions in patients with
•• Decreases the benign/malignant ratio of excised multiple N present irregular dermoscopic patterns, which
lesions; this expresses how many benign lesions are means that many unnecessary excisions are still performed.
necessary to excise in order to detect an M. In preder
moscopic era this ratio was 18/1 and it has decreased So, What Can We Do? (Figs. 6.224 and 6.225)
to 4/1 in dermoscopic era. It is therefore necessary to have a more reliable detection
•• Has improved the sensitivity and, to a lesser extent, the strategy than just the clinical and dermoscopic ones and
specificity; sensibility refers to the capacity to detect M, the option is the comparative approach in which individual
while specificity refers to the capacity to detect non-M. lesions are evaluated in the context of the patient’s general
In the formula of specificity are the false positives, N profile.
Fig. 6.210: Low-risk patients. Fig. 6.211: Low-risk patients with very few nevi underwent a melanoma
excision from the right leg.
Fig. 6.212: Clinical features of high-risk patients. Fig. 6.213: High-risk patients with multiple nevi.
Fig. 6.214: Usefulness of dermoscopy in melanoma detection. Fig. 6.215: Sensitivity refers to the capacity to detect melanoma.
Fig. 6.217: Specificity refers to the capacity to detect nonmelanomas.

Fig. 6.216: Sensitivity refers to the capacity to detect melanoma. In
these examples, the melanoma is quickly identified (red dot).
Fig. 6.219: The decrease in the number of biopsies, the fall in the
Fig. 6.218: Specificity refers to the capacity to detect nonmelanomas.
benign/malignant relationship and the improvement in sensitivity
In this example it is very difficult to distinguish which is the melanoma.
and specificity has been reached by studying individual lesions.
In fact, any of them could be it since nevi with severe dysplasia are
almost indistinguishable from melanoma in situ.
Fig. 6.220: Different strategies in patients with multiple nevi.
A B
Figs. 6.221A and B
Figs. 6.221A to C: (A) Dermoscopy approach in patients with multiple

nevi: biopsies and excisions. (B) Dermoscopy approach in patients
(56-year-old) with multiple nevi: biopsies and excisions—this is an
example of what not to do. (C) Dermoscopy approach in patients
(11-year-old) with multiple nevi: biopsies and excisions—this is an
C example of what not to do.
A B
Figs. 6.222A and B: (A) Dermoscopy approach in patients with multiple nevi: usefulness of clinical ABCD rule. (B) Dermoscopy approach in
patients with multiple nevi: Nevus or melanoma? The clinical ABCD rule is not helpful in small lesions (b is melanoma).
Fig. 6.223: Dermoscopy approach in patients with multiple nevi: only Fig. 6.224: It is therefore necessary to have a more reliable detection
dermoscopy is not enough because many benign lesions in patients strategy than just the clinical and dermoscopic ones and the option is
with multiple nevi present irregular dermoscopic patterns, which the comparative approach.
means that many unnecessary excisions are still performed.
Fig. 6.225: Two different (complementary) dermoscopic approaches.
A B
Figs. 6.226A and B: (A) The morphological dermoscopic approach: nevus with atypical dermoscopic features, we should remove this. (B)
Comparative dermoscopic approach: the same patient as in Figure 6.226A, these nevi have atypical dermoscopic features but are all similar with
one another. Now, with this comparative approach we do not need to remove.
In this manner we would have two different and com dermoscopic features, they are all similar to one another
plementary dermoscopic approaches (Figs. 6.226A and B): (Figs. 6.229 to 6.233).
•• The morphological dermoscopic approach—assess The different lesions are (Fig. 6.234):
ment of only one lesion. •• Ugly duckling sign: A lesion clinically or dermoscop
•• Comparative dermoscopic approach (Fig. 6.227) ically different from the predominant N pattern in a
–– Assessment of multiple lesions with a view to reco given patient. It may not present the specific dermo
gnizing the: scopic criteria for M and yet be one (Figs. 6.235 to 6.237).
–– Predominant N pattern (signature N; Fig. 6.228) •• Little red riding hood sign: Especially in patients with
–– The different lesion (Fig. 6.234) multiple atypical N. It is that lesion which is clinically
▪▪ Ugly duckling sign similar to the others but under dermoscopy is highly
▪▪ Little red riding hood sign suspicious of being an M (Figs. 6.238 to 6.241).
Predominant N pattern (signature nevus): It is the pre Conclusion: It has been proved that with the compara
dominant group of N sharing the same clinical or dermo tive approach about 30% fewer N are excised than with just
scopic appearance; although they may present atypical the morphologic approach.
Fig. 6.227: Comparative dermoscopic approach. Fig. 6.228: Signature nevus.
A B
Figs. 6.229A and B: Signature nevi: (A) Patients with multiple clinical atypical nevi. (B) All of these nevi present the same typical dermoscopy
pattern (mixed central pattern).
A B
pattern.
A B
pattern.
A B
Figs. 6.232A and B: Signature nevi: (A) Patients with multiple clinical atypical nevi. (B) All of these nevi present an atypical dermoscopy pattern.
A B
pattern.
Fig. 6.234: The different lesion: ugly duckling sign and little red riding Fig. 6.235: Ugly duckling sign: a lesion clinically or dermoscopically
hood sign. different from the predominant nevi pattern in a given patient.
Fig. 6.236: Ugly duckling sign: this nevus is different under clinical Fig. 6.237: Ugly duckling sign: this nevus is different under clinical
(red dot) and dermoscopy (red dot) examination. (red dot) and dermoscopy examination.
Fig. 6.238: Little red riding hood sign: it is that lesion that is clinically Fig. 6.239: Little red riding hood sign: the nevus in the red circle is
similar to the others but under dermoscopy is highly suspicious of clinically similar to the others but under dermoscopy (red dot) is highly
being a melanoma. suspicious of being a melanoma (superficial spreading melanoma B 0.30).
Fig. 6.240: Little red riding hood sign: the nevus in the red circle is Fig. 6.241: Little red riding hood sign: the nevus in the red circle is
clinically similar to the others but under dermoscopy (red dot) is highly clinically similar to the others but under dermoscopy (red dot) is highly
suspicious of being a melanoma (superficial spreading melanoma in situ). suspicious of being a melanoma (superficial spreading melanoma B 0.40).
SUGGESTED READING Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat

tern Analysis. Austria: Facultas.wuv; 2011.
Argenziano G, Catricalà C, Ardigo M, et al. Dermoscopy of Lallas A. Dermoscopy in general dermatology. Dermatol Clin.
patients with multiple nevi. Improved management recom 2013;3:679-94.
mendations using a comparative diagnosis approach. Arch Lin W, Luo S, Muzikansky A, et al. Outcome of patients with de
Dermatol. 2011;147(1):46-9.
novo versus nevus-associated melanoma. J Am Acad Derma
Argenziano G, Cerroni L, Zalaudek I, et al. Accuracy in melanoma
tol. 2015;72:54-8.
detection: a 10-year multicenter survey. J Am Acad Dermatol.
2012;67(1):54-9.
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas ciones Gráficas; 2009.
of Dermoscopy. Milán: EDRA Medical Publishing & New Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
Media; 2000. Taylor & Francis; 2005.
Argenziano G, Zalaudek I, Hofmann-Wellenhof R, et al. Total body Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
skin examination for skin cancer screening in patients with copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
focused symptoms. J Am Acad Dermatol. 2012;66(2):212-9. Company; 1996.
Ediciones Journal; 2012. mented Skin Lesions. An Atlas Based on the Consensus Net
Carli P, de Giorgi V, Chiarugi A, et al. Addition of dermoscopy to Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
conventional naked-eye examination in melanoma screen New Media; 2001.
ing: a randomized study. J Am Acad Dermatol. 2004;50:683-9. Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
Carli P, de Giorgi V, Crocetti E, et al. Improvement of malignant/
copy. Germany: Blackwell Science; 1994.
benign ratio in excised melanocytic lesions in the “dermos
Terushkin V, Warycha M, Levy M, et al. Analysis of the benign to
copy era”: a retrospective study 1997-2001. Br J Dermatol.
malignant ratio of lesions biopsied by a general dermatolo
2004;150(4):687-92.
Jaimes N, Dusza SW, Quigley EA, et al. Influence of time on der gist before and after the adoption of dermoscopy. Arch Der
moscopic diagnosis and management. Australas J Dermatol. matol. 2010;146(3):343-4.
2013;54(2):96-104. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-Pig
Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment mented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
Guide, 2nd edition. New York: McGraw-Hill Education; 2015. Zalaudek I, Argenziano G, Mordente I, et al. Nevus type in der
Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials moscopy is related to skin type in white persons. Arch Der
(MOABT). New York: Elsevier Ltd; 2004. matol. 2007;143(3):351-6.
MELANOMA SIMULATORS 7
Horacio A Cabo
“In this chapter are included all those lesions that may simulate a melanoma,
both clinically and dermoscopically.
They can be divided into two groups, nonmelanocytic melanoma simulators, such as basal cell carcinoma,
squamous cell carcinoma and actinic keratosis, ink-spot lentigo, seborrheic keratosis, dermatofibroma,
thrombosed hemangioma and hematomas, pyogenic granuloma, eccrine poroma and collision tumors;
melanocytic melanoma simulators also will be treated, atypical nevus (Clark’s nevus), recurrent nevus,
combined nevus, blue nevus, Spitz-Reed nevus, melanocytic maculae and longitudinal melanonychia.”
Melanoma Simulators 207
In this chapter all those lesions are included that may sim- •• Hematomas
ulate a melanoma, both clinically and dermoscopically. •• Pyogenic granuloma
They can be divided into two groups. •• Eccrine poroma
•• Collision tumors
NONMELANOCYTIC MELANOMA MELANOCYTIC MELANOMA
SIMULATORS (FIGS. 7.1 TO 7.12) SIMULATORS (FIGS. 7.13 TO 7.20)
•• Basal cell carcinoma •• Atypical nevus (Clark’s nevus)
•• Squamous cell carcinoma •• Recurrent nevus
•• Actinic keratosis •• Combined nevus
•• Ink-spot lentigo •• Blue nevus
•• Seborrheic keratosis •• Spitz-Reed nevus
•• Dermatofibroma •• Melanocytic maculae
•• Thrombosed hemangioma •• Longitudinal melanonychia
A B
Figs. 7.1A and B: (A) Basal cell carcinoma (BCC); clinical view and (B) Pigmented BCC; dermoscopy view.
A B
Figs. 7.2A and B: (A) Basal cell carcinoma (BCC); clinical view and (B) Pigmented BCC; dermoscopy view.
A B
Figs. 7.3A and B: (A) Squamous cell carcinoma (SCC); clinical view and (B) Pigmented SCC; dermoscopy view.
Fig. 7.4: Pigmented actinic keratosis.
A B
Figs. 7.5A and B: (A) Ink-spot lentigo; clinical view and (B) Ink-spot lentigo; dermoscopy view.
Fig. 7.6: Pigmented seborrheic keratosis; clinical and dermoscopy view.
A B
Figs. 7.7A and B: (A) Dermatofibroma; clinical view and (B) Dermatofibroma; dermoscopy view.
A B
Figs. 7.8A and B: (A) Thrombosed hemangioma; clinical view and (B) Thrombosed hemangioma; dermoscopy view.
A B
Figs. 7.9A and B: (A) Subungual hematomas; clinical image and (B) Subungual hematomas; dermoscopy view.
A B
Figs. 7.10A and B: (A) Pyogenic granuloma; clinical image and (B) Pyogenic granuloma; dermoscopy image.
Fig. 7.11: Eccrine poroma; clinical and dermoscopy view.

A B
Figs. 7.12A and B: (A) Collision tumors clinical view and (B) Collision tumors dermoscopy view—basal cell carcinoma (red arrow) and seborrheic
keratosis (white arrow).
Fig. 7.13: Different dermoscopy images of atypical nevus (Clark’s nevus).
A B
Figs. 7.14A and B: (A) Recurrent nevus; clinical view and (B) Recurrent nevus; dermoscopy image.
A B
Figs. 7.15A and B: (A) Combined nevus; clinical view and (B) Combined nevus; dermoscopy view (blue nevus and compound nevus).
Fig. 7.16: Atypical blue nevus. Fig. 7.17: Atypical Spitz nevus.
Figs. 7.18: Atypical Spitz nevus.

A B
Figs. 7.19A and B: (A) Melanotic labial macule; clinical view and (B) Melanotic labial macule; dermoscopy view with the classical “Fish scale-like
pattern.”
Table 7.1 Melanoma simulators.

Non melanocytics Melanocytics
Basal cell carcinoma Clark’s nevus
Squamous cell carcinoma Recurrent nevus
Actinic keratosis Combined nevus
Ink spot lentigo Blue nevus
Seborrheic keratosis Spitz-Reed nevus
Dermatofibroma Melanotic maculae
Thrombosed hemangioma Longitudinal melanonychia
Hematomas
Pyogenic granuloma
Eccrine porome
Fig. 7.20: Longitudinal melanonychia. Collision tumors
Even though these lesions have been described in pre- Lallas A. Dermoscopy in general dermatology. Dermatol Clin.
vious chapters, we herein illustrate them with examples of 2013;3:679-94.
the different cases (Table 7.1). Malvhey J, Puig S. Principles of dermoscopy. Barcelona: Crea-
Marghoob A, Braun R, Kopf A. Atlas of dermoscopy. London:
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Menzies S, Crotty K, Ingvar C, et al. An atlas of surface micros-
of Dermoscopy. Milán: EDRA Medical Publishing & New copy of pigmented skin lesions. Sydney: McGraw-Hill Book
(MOABT). New York: Elsevier Ltd; 2004. Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos-
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat- copy. USA: Blackwell Science; 1994.
tern Analysis. facultas.wuvUniversitätsverlag, Austria www. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-
facultas.wuv.at Pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
COMBINED LESIONS 8
Horacio A Cabo
“Combined lesions are formed by two or more cutaneous lesions of different origin. These lesions
do not include combined nevus developed on melanocytic nevus, due to their melanocytic origin.
There is no association pattern between these lesions; in fact,
in most cases,finding them is fortuitous and unexpected.”
Combined Lesions 217
Combined lesions are formed by two or more cutaneous •• Squamous cell carcinoma (SCC)
lesions of different origin. These lesions do not include •• Dermatofibroma (D)
combined nevus nonmelanoma developed on melano- •• Sebaceous hyperplasia (SH)
cytic nevus, due to their melanocytic origin. With reference to SK, it is important to take into
There is no association pattern between these lesions; account that, since this is the most frequent benign cuta-
in fact, in most cases, finding them is fortuitous and unex- neous tumor—which may combine with any of the previ-
pected. ously described lesions—it is possible to find it in many of
According to the literature, the manifestation fre- the observed combined lesions; even, on occasion, associ-
quency is low: 0.06%. However, it is suspected to be higher. ated with more than one lesion.
Malignant tumors combined with SK are, in order of
Dermoscopy is very useful to diagnose combined
frequency, BCC, SCC, and M, and the most affected area is
lesions, since it makes it possible to observe the structures
the back.
and patterns characteristic of each lesion, which have been
It is estimated that the frequency of combination of SK
described in detail in the different chapters of this book.
and BCC—considering the incidence of these tumors—
The combinations most frequently observed are between
is higher than the reported one. A possible explanation
the following lesions: behind this could be that BCC might progressively destroy
•• Hemangioma (H) SK, or that residual SK may be overlooked in the histo-
•• Seborrheic keratosis (SK) pathological examination.
•• Solar lentigo (SL) In conclusion, in the face of a pigmented lesion pre-
•• Lentigo (L) senting dermoscopic criteria corresponding to different
•• Basal cell carcinoma (BCC) lesions, whether melanocytic or nonmelanocytic, the
•• Nevus (N) possibility of a combined lesion must be considered (Figs.
•• Melanoma (M) 8.1 to 8.14).
Fig. 8.1: Seborrheic keratosis (red arrow); junction nevus (white arrow).
Fig. 8.2: Seborrheic keratosis (red arrow); junction nevus (white arrow).
A B
Figs. 8.3A and B: (A) Nevus (red arrow); dermatofibroma (white arrow) and (B) Nevus (left side); dermatofibroma (right side).
Fig. 8.4: Seborrheic keratosis (white arrow); angioma (red arrow); Fig. 8.5: Nevus (red arrow); dermatofibroma (white arrow).
junction nevus (black arrow).
Fig. 8.6: Nevus (red arrow); angioma (white arrow). Fig. 8.7: Seborrheic keratosis (red arrow); basal cell carcinoma (white
arrow).
Combined Lesions 219
Fig. 8.8: Seborrheic keratosis (red arrow); basal cell carcinoma (white Fig. 8.9: Seborrheic keratosis (red arrow); basal cell carcinoma (white
arrow). arrow) clinical view (black arrow).
Fig. 8.10: Seborrheic keratosis (red arrow); basal cell carcinoma (white Fig. 8.11: Seborrheic keratosis (red arrow); basal cell carcinoma (white
arrow). arrow).
Fig. 8.12: Congenital nevus (red arrow); basal cell carcinoma (white Fig. 8.13: Sebaceous hyperplasia (white arrow); seborrheic keratosis
arrow). (red arrow).
Fig. 8.14: Seborrheic keratosis (white arrow); senile purpura (red arrow).
SUGGESTED READING and a melanocytic nevus mimicking melanoma. Dermatol

Pract Concept. 2015;5(4):47-9.
2000. Company; 1996.
(MOABT). New York: Elsevier Ltd; 2004. Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat New Media; 2001.
tern Analysis 2011 Facultas Verlags- und Buchhandels AG Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at copy. USA: Blackwell Science; 1994.
Lallas A. Dermoscopy in General Dermatology. Dermatol Clin. Zaballos P, Bañuls J, Cabo H, et al. The usefulness of dermos-
2013;3:679-94. copy for the recognition of basal cell carcinoma–sebor-
Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea- rhoeic keratosis compound tumors. Australas J Dermatol.
ciones Gráficas; 2009. 2013;54(3):208-12.
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findings in a collision tumor composed of a dermatofibroma mented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
SPECIAL LOCATIONS 9
Horacio A Cabo
“The dermoscopy features in especial locations of pigmented and nonpigmented
lesions are a very important issue.
Diagnosis and treatment of pigmented maculae on the face is one of the most difficult
scenarios in the daily practice, even using a dermoscope.
To the acral site lesions, it is absolutely necessary to know the anatomy and histology
of palms and soles that is different from the rest of the skin.
Dermoscopy have provided to improve the diagnosis of mucosa and nail lesions as well.”
Special Locations 223
9.1 FACE
Horacio A Cabo
Diagnosis and treatment of pigmented maculae on the already been described, and therefore we will here discuss
face is one of the most difficult scenarios in the daily prac them in less detail.
tice, even using a dermoscope. The natural course and
the prognosis are different in these pathologies, so that an
Dermoscopic Criteria for SL (Fig. 9.5)
accurate diagnosis is essential in order to guarantee a suit Fingerprint-Like Structures
able management and treatment.
These are brown structures, made up of fine parallel
The face has a particular anatomic characteristic. In
adult facial skin, the rete ridge is flattened or completely lines in fingerprint fashion. They are usually found in the
absent, which means that it is not possible to observe peripheral part of the lesion.
pigment network. The hair follicle opening, just like the Moth-Eaten Border
sebaceous glands and sweat glands, has no pigment and
Concave edge of the lesion resembling the bite of a moth.
presents a pseudonetwork formed by a thick mesh result
ing from the skin color and whitish gaps, which corre Jelly Sign
spond to the openings of the glands, since these areas lack Light brown or yellowish in color; it resembles a very
melanin pigment. Therefore, this pseudonetwork is found thin layer of jelly which has dried or a film covering the
in both melanocytic and nonmelanocytic lesions of the surface of the skin.
face, and consequently the pseudonetwork does not dif
ferentiate melanocytic from nonmelanocytic lesions in the Dermoscopic Criteria for (AKs (Figs. 9.6 to 9.8)
case of the face, which makes it necessary to use other cri
teria (Figs. 9.1 to 9.3). Nonpigmented AK
In the face, the most important differential diagnosis is •• Strawberry-like pattern: It is possible to observe white
between lentigo maligna melanoma (LMM), solar lentigo or white-yellow follicular openings, in a reddish back
(SL), pigmented and nonpigmented actinic keratosis ground resembling the surface of a strawberry.
(PAK-AK) and lichen planus-like keratosis (Fig. 9.4). •• Vascular pattern with fine undulated vessels surround
Solar lentigo (Chapter 5, Part 5.2), PAK and AK (Chap ing the hair follicle, dot-like vessels, and spiral-like
ter 5, Part 5.6), and LMM (Chapter 6, Part 6.9.3) have vessels.
Fig. 9.1: Particular anatomic characteristic of the face. Fig. 9.2: Histologic differences between face and forearm skins.
Fig. 9.3: Difference between light and dark skins. In dark skin, a physio Fig. 9.4: The most important differential diagnosis in the face
logic pseudonetwork is clearly observed.
Fig. 9.5: Solar lentigo. Red arrows: Moth-eaten border. Black arrow: Fig. 9.6: Actinic keratosis: Strawberry pattern (white circle); Rosette-
Fingerprint-like structures. like structures (arrow).
Fig. 9.7: Pigmented (black circle) and nonpigmented (red circle) Fig. 9.8: Pigmented actinic keratosis: Pigmentation of the follicular
actinic keratosis in the same lesion. openings (white circle); Rosette-like structures (arrow).
•• Superficial yellowish-white scales. pseudonetwork. It is the result of the pigmentation of

•• Hyperkeratotic follicles. the basal keratinocytes surrounding the hair follicle.
•• Rosettes: They are observable with polarized light and •• Asymmetric pigmentation of the follicular opening
correspond to four grouped white dots, resembling a [which can also be found in lentigo maligna (LM)].
four-leafed clover, located mainly within the follicular •• Rhomboidal structures (also found in LM).
opening. They are nonspecific, and observable also in
other tumors, especially keratinizing ones. Dermoscopic Criteria for Lichen
Planus-Like Keratosis
Pigmented AK
(Figs. 9.9 to 9.12)
•• Superficial brown color with the appearance of broken
pseudonetwork. •• Lichen planus-like keratosis is a SL or seborrheic kera
•• Hyperkeratotic follicles. tosis (SK) with regression which may simulate a LM. In
•• Inner gray halo: Subtle homogeneous gray or light lesions with incomplete regression, it is important to
brown halo surrounding the follicular openings in the examine the areas of the pre-existing lesion (SK or SL).
manner of an inner ring within the mesh of the brown When regression is complete, there appear gray dots,
Fig. 9.9: Lichen planus-like keratosis: Seborrheic keratosis with regres Fig. 9.10: Lichen planus-like keratosis: Actinic keratosis with regression
sion (arrow). (white circle).
Fig. 9.11: Lichen planus-like keratosis: Actinic keratosis with regression Fig. 9.12: Lichen planus-like keratosis: Actinic keratosis with regression
(white circle). (arrows).
Fig. 9.13: Lentigo maligna: Blue-gray pigmented follicular openings Fig. 9.14: Lentigo maligna: Asymmetric pigmentation of the follicular
(black arrow); asymmetric pigmentation of the follicular openings (red openings (red arrows); circle within a circle (white arrows).
arrows); circle within a circle (white arrow).
globules, lines or even rhomboid structures. In these SUGGESTED READING

cases, a biopsy is recommended.
Dermoscopic Criteria for LM (Figs. 9.13 and 9.14) of Dermoscopy. Milán: EDRA Medical Publishing & New
Media; 2000.
Dermoscopic Features Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro;
•• Blue-gray color: Sometimes, this color is the only clue 2000.
to suspect a malignant lentigo. Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina:
•• Blue, gray, or black pigmented and asymmetrically pig Ediciones Journal; 2012.
mented follicular openings: Dark brown or black in Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment
color, which indicates the irregular proliferation of Guide, 2nd edition. New York: McGraw-Hill Education; 2015.
atypical melanocytes within the follicles. In LM (mela
(MOABT). New York: Elsevier Ltd; 2004.
noma in situ) and in LMM (invasive melanoma), if the
follicles are close together, it is possible to perceive a
second pseudonetwork characterized by a thin mesh, facultas wuv Universitätsverlag, Austria www.facultas.wuv.at
as opposed to the pseudonetwork which depends on Lallas A. Dermoscopy in general dermatology. Dermatol Clin.
location and which presents a thick mesh. These grid- 2013;3:679-94.
like structures are pseudonetworks, since they do not Malvhey J, Puig S. Principles of dermoscopy. Barcelona: Crea
arise from the pigmentation of the crests or ridges of ciones Gráficas; 2009.
the rete ridges but from the follicular openings in pig Marghoob A, Braun R, Kopf A. Atlas of dermoscopy. London:
mented facial skin. Taylor & Francis; 2005.
•• Two concentric circles (circle within a circle): This new Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
criterion is highly useful and its significance, statisti copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
cally undetermined yet, could be similar to that of the Company; 1996.
asymmetric pigmentation of the follicular openings.
•• Slate gray dots around the follicular openings: It is an
early sign of lentigo malignant and it is the beginning
of granular–annular pattern. Meeting on Dermoscopy. Milán: EDRA Medical Publishing &
•• Rhomboidal structures: At a later stage, it is possible New Media; 2001.
to detect dark brown or black lines or short streaks, Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
highly specific around the follicles. copy. USA: Blackwell Science; 1994.
•• Homogeneous blue-gray areas with the hair follicles Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Nonpig
spared or obliterated. mented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
9.2 PALMS AND SOLES

Horacio A Cabo
In this chapter, we will talk about benign lesions in this presence of pigment, especially in the furrow, which con
location since the dermoscopic features of acral mela figures a characteristic parallel pattern.
noma have been described in Chapter 6, Part 6.9.4. Variants:
It is absolutely necessary to know the anatomy and •• One line (Figs. 9.16 to 9.25)
histology of palms and soles (Fig. 9.15). •• Double line (Figs. 9.26 to 9.33) (it probably corre
The main anatomical feature is that the cutaneous sur sponds to the congenital type acral nevus)
face presents dermatoglyphs composed of ridges and fur •• Dotted line (Fig. 9.34)
rows, which are characteristic of each individual through •• Double-dotted line (Figs. 9.35 to 9.37)
genetic determination. Skin histology shows particular Lattice-like pattern: Variant of the parallel furrow pat
features due to the thickness of the corneum layer, the tern. It is the second most frequent pattern (14%). It is a
absence of hair follicles, the presence of eccrine glands, parallel furrow pattern with lines crossing the crista from a
and the repetition of crista intermedia and crista limitans furrow to the next (Figs. 9.38 to 9.43).
in the dermoepidermal junction, as shown in Figure 9.15. Fibrillar pattern: It is composed of usually delicate
Characteristically, eccrine glands are located in the lines streaming from the sulcus and crossing many fur
crista intermedia; therefore, their eccrine ducts lead to the
rows and ridges in a discretely oblique fashion. This pig
surface of the ridge.
ment pattern results from the optic effect of the fold of the
In the case of benign melanocytic lesions, the nests of
ridges in higher pressure areas of palms and soles (Figs.
melanocytes tend to lie fundamentally in the crista limi
9.44 to 9.49).
tans and this produces the pigmentation of the furrows.
Globular pattern: Similar to that observed in other
This phenomenon, of unknown origin, gives rise to the
melanocytic lesions (Fig. 9.50).
dermoscopic patterns.
Homogeneous pattern: Some congenital nevi may
show a homogeneous brown or blue pattern (Fig. 9.51).
DERMOSCOPIC PATTERNS Reticular pattern: Similar to nevi with reticular pattern
OF ACRAL NEVI (Figs. 9.52 to 9.55).
Parallel furrow pattern: It is the most frequent pattern Atypical or uncharacteristic pattern: Those lesions that
in acral lesions, both in Asian and Caucasian races, and cannot be classified as corresponding to any of the previ
represents 50% of all melanocytic nevi. It consists in the ous patterns (Fig. 9.56).
Fig. 9.15: Scheme of the skin anatomy in palms and soles. Fig. 9.16: Parallel furrow pattern: One line.
Fig. 9.17: Parallel furrow pattern: One line. Fig. 9.18: Parallel furrow pattern: One line.
Fig. 9.25: Parallel furrow pattern: One line. Fig. 9.26: Parallel furrow pattern: Double line.
Fig. 9.27: Parallel furrow pattern: Double line. Fig. 9.28: Parallel furrow pattern: Double line.
Fig. 9.33: Parallel furrow pattern: Double line. Fig. 9.34: Parallel furrow pattern: Dotted line.
Fig. 9.35: Parallel furrow pattern: Double-dotted line. Fig. 9.36: Parallel furrow pattern: Double-dotted line.
Fig. 9.37: Parallel furrow pattern: Double-dotted line. Fig. 9.38: Lattice-like pattern.
Fig. 9.39: Lattice-like pattern. Fig. 9.40: Lattice-like pattern.

Fig. 9.41: Lattice-like pattern. Fig. 9.42: Lattice-like pattern.
Fig. 9.43: Lattice-like pattern. Fig. 9.44: Fibrillar pattern.
Fig. 9.45: Fibrillar pattern. Fig. 9.46: Fibrillar pattern.

Fig. 9.47: Fibrillar pattern. Fig. 9.48: Fibrillar pattern.
Fig. 9.49: Fibrillar pattern. Fig. 9.50: Globular pattern.
Fig. 9.51: Homogeneous pattern. Fig. 9.52: Reticular pattern.

Fig. 9.53: Reticular pattern. Fig. 9.54: Reticular pattern.
Fig. 9.55: Reticular pattern. Fig. 9.56: Atypical or uncharacteristic pattern.
Transition pattern: In the case of localized lesions in

the transition zone between volar skin and the back of
hands and feet (Wallace line), there is a transition pattern
combining benign parallel pattern and reticular pig
mented pattern (Figs. 9.57 and 9.58).
Congenital nevus: Nevi showing crista dotted pattern
and the double line variant (Figs. 9.26 to 9.59).
Pseudoparallel-ridge pattern: After trauma in palms
and soles, the hemorrhage flows through the duct of the
eccrine sweat gland and reaches the epidermis causing a
pigmentation of the ridge due to hematic pigment (Figs.
9.60 to 9.64).
Main characteristics:
•• Previous trauma history (not always remembered) Fig. 9.57: Transition pattern.
Fig. 9.58: Transition pattern. Fig. 9.59: Congenital nevus: Crista dotted pattern.
Fig. 9.60: Pseudoparallel-ridge pattern: After trauma in palms and Fig. 9.61: Pseudoparallel-ridge pattern: After trauma in palms and
soles, the hemorrhage flows through the duct of the eccrine sweat soles, the hemorrhage flows through the duct of the eccrine sweat
gland and reaches the epidermis causing a pigmentation of the ridge gland and reaches the epidermis causing a pigmentation of the ridge
due to hematic pigment. due to hematic pigment.
Fig. 9.62: Pseudoparallel-ridge pattern: After trauma in palms and soles,

the hemorrhage flows through the duct of the eccrine sweat gland and
reaches the epidermis causing a pigmentation of the ridge due to hematic
pigment.
Fig. 9.63: Pseudoparallel-ridge pattern: After trauma in palms and Fig. 9.64: Pseudoparallel-ridge pattern: After trauma in palms and
soles, the hemorrhage flows through the duct of the eccrine sweat soles, the hemorrhage flows through the duct of the eccrine sweat
gland and reaches the epidermis causing a pigmentation of the ridge gland and reaches the epidermis causing a pigmentation of the ridge
due to hematic pigment. due to hematic pigment.
•• Typical color Lallas A. Dermoscopy in general dermatology. Dermatol Clin.

•• Regularity 2013;3: 679-94.
•• Color changes accompanying hematoma resolution
Argenziano G, Soyer P, De Giorgio V, et al. Interactive Atlas Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros
Ediciones Journal; 2012. mented Skin Lesions. An Atlas Based on the Consensus Net
Guide, 2nd edition. New York: Mc-Graw Hill Education; 2015. New Media; 2001.
Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
(MOABT). New York: Elsevier Ltd; 2004.
copy. USA: Blackwell Science; 1994.
tern Analysis 2011 Facultas Verlags- und Buchhandels AG Suzaki R, Ishizaki S, Iyatomi H, et al. Age-related prevalence of
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at dermoscopic patterns of acral melanocytic nevi. Dermatol
Koga H, Saida T. Revised 3-step dermoscopic algorithm for the Pract Concept. 2013;4(1):53-7.
management of acral melanocytic lesions. Arch Dermatol. Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-pig
2011;(6):741-2. mented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
9.3 MUCOSA
Horacio A Cabo
The mucosa has a special epithelial type characterized by its we think it is more useful to focus the dermatoscopy of
thinness and being constantly lubricated. The horny layer mucous membranes (on?) recognizing patterns associ
or stratum corneum, granular layer, and sweat glands are ated with benign lesions and others associated with malig
absent, as opposed to what happens with the skin, which is nant lesions, in order to make the decision to biopsy or
why the observable dermoscopic criteria are different. not the lesion. (whether to biopsy the lesion or not).
The pigmented lesions on the mucosae encompass a
range of different entities which may have melanocytic
DERMOSCOPIC PATTERNS
origin or result from a precipitate of melanin pigment or of
other substances with exogenous or endogenous origin. Benign pigmented lesions
The most frequent scenario is the melanocytic Mac •• Dotted-globular pattern (Figs. 9.65 to 9.69)
ula, labial or genital, and has a typical dermatoscopy, but •• Homogeneous pattern (Fig. 9.68)
Fig. 9.65: Melanocytic nevus (lip): Dotted-globular pattern. Fig. 9.66: Labial melanotic macule: dotted-globular pattern (arrow).
Fig. 9.67: Labial melanotic macule: Dotted-globular pattern (arrow). Fig. 9.68: Genital melanotic macule: Homogeneous pattern.
•• Fingerprint-like pattern (Figs. 9.69 and 9.70)

•• Fish scale-like pattern
•• Hyphal pattern (Figs. 9.71 to 9.80)
•• Ring-like pattern
Angioma (Fig. 9.81)
•• Lichenoid chronic cheilitis (Figs. 9.82 and 9.83)
•• Pigmented lichen planus (Fig. 9.84)
•• Tattoos due to amalgama (Fig. 9.85)
Melanoma (Figs. 9.86 and 9.87)
•• Multicomponent pattern and homogeneous pattern
–– Recently, we have found that the presence of struc
tureless zones inside the lesions with blue, gray, or
white color have:
Fig. 9.69: Genital melanotic macule: Fingerprint-like pattern.
▪▪ For melanoma 100% sensitivity
Fig. 9.70: Genital melanotic macule: Fingerprint-like pattern. Fig. 9.71: Dermoscopic patterns associated with benign lesions.
Fig. 9.72: Labial melanotic macule: Dotted-globular pattern (yellow Fig. 9.73: Labial melanotic macule: Fish scale-like pattern (arrows).
arrow); fish scale-like pattern (white arrow).
Fig. 9.74: Labial melanotic macule: Fish scale-like pattern. Fig. 9.75: Labial melanotic macule: Fish scale-like pattern.
Fig. 9.76: Labial melanotic macule: Fish scale-like pattern. Fig. 9.77: Labial melanotic macule: Fish scale-like pattern.
Fig. 9.78: Genital melanotic macule: Fish scale-like pattern (white Fig. 9.79: Labial melanotic macule: Dotted-globular pattern (yellow
circles). arrow); hyphal pattern (white arrow); ring-like pattern (red arrow).
Fig. 9.80: Labial melanotic macule: Ring-like pattern (arrow). Fig. 9.81: Angioma (lip).
Fig. 9.82: Lichenoid chronic cheilitis. Fig. 9.83: Lichenoid chronic cheilitis.
Fig. 9.84: Pigmented lichen planus. Fig. 9.85: Tattoos due to amalgama.
Fig. 9.86: Multicomponent pattern (melanoma). Fig. 9.87: Dermoscopy of pigmented lesions of the mucosa and the
mucocutaneous junction.
▪▪ 82.2% specificity junction: results of a multicenter study by the Interna

▪▪ For any malignant lesion 92.9% sensitivity tional Dermoscopy Society (IDS). Arch Dermatol. 2011;147
(10):1181-7.
▪▪ 83.3% specificity (Fig. 9.87)
Ferrari, A, Zalaudek I, Argenziano G, et al. Dermoscopy of pig
mented lesions of the vulva: A Retrospective Morphological
SUGGESTED READING Study. Dermatology. 2011;222:157-66.
Lin J, Koga H, Takata M, et al. Dermoscopy of pigmented lesions
Blum A, Simionescu O, Argenziano G, et al. Dermoscopy of mucocutaneous junction and mucous membrane. BJD. 2009;
pigmented lesions of the mucosa and the mucocutaneous 161:1255-61.
9.4 NAILS
Horacio A Cabo
The main objective is to recognize a melanoma in the nail –– Homogeneous coloration

apparatus with a high sensitivity when in the presence of a –– Multiple nails involvement
longitudinal melanonychia. Different structures are recognizable
There are many other benign conditions which may •• Hemorrhagic spots
present as a longitudinal melanonychia: nevi, lentigo, eth •• Brown background
nic variation, subungual hemorrhages, and drug-induced –– Regular parallel longitudinal lines
pigmentation. –– Irregular parallel longitudinal lines
It is important to take into account that longitudinal •• Gray background
biopsy is still the gold standard for a definite diagnosis, –– Regular gray lines
although the dermoscopic analysis of the lesion enables •• Micro-Hutchinson sign
the identification of the most suspicious cases, avoiding a
surgical biopsy, which is always technically difficult, pain HEMORRHAGIC SPOTS
ful and, on occasion, leading to a permanent dystrophy of (FIGS. 9.88 TO 9.92)
the explored nail.
Lesion color ranges between red, purple, and brown. It
Nail dermoscopy may be performed by means of any
is blue-purple for recent lesions and black-brown for old
model of handheld dermoscope and it is advisable to use a
lesions.
colorless ultrasound gel.
However, in all these lesions the proximal area remains
The clinical features are important:
polycyclic or round, while the distal area is elongated or
•• Suspicious features
lineal. (Parallel lineal pattern in splinter hemorrhages).
–– The occurrence of melanonychia in adults
Follow up the lesion and rule out melanoma and SCC
–– A single melanonychia
without history of trauma (Fig. 9.93).
–– Heterogeneous pigmentation
–– Progressive melanonychia onset with the proximal
area wider than the distal area
BROWN BACKGROUND
•• Features usually associated with benign conditions This pattern corresponds to the association of regular or
–– Manifestation during infancy irregular pigmented lines on a homogeneous brown back
–– Stable over time ground, corresponding to the pigmented band.
Fig. 9.88: Subungual hemorrhage: Blue-purple lesions with lineal Fig. 9.89: Subungual hemorrhage: Blue-purple lesions with lineal
distal area (parallel lineal pattern in splinter hemorrhages). distal area (parallel lineal pattern in splinter hemorrhages).
Fig. 9.90: Subungual hemorrhage: Blue-purple lesions with lineal Fig. 9.91: Subungual hemorrhage: Brown color (old lesions).
distal area (parallel lineal pattern in splinter hemorrhages).
Fig. 9.92: Subungual hemorrhage: Brown color (old lesions). Fig. 9.93: Subungual hemorrhage due to squamous cell carcinoma.
Regular Parallel Longitudinal Lines

(Figs. 9.94 to 9.98)
These appear overlapping the background homogeneous
pattern.
The regular pattern points to a benign condition (nevi).
It consists in:
•• Regular spacing, width and coloration
•• Absence of parallel disruption or no loss of parallelism
•• All lines have the same shade and width
•• Brown or black color points to melanocytic hyperplasia
Irregular Parallel Longitudinal Lines

(Figs. 9.99 and 9.100)
Fig. 9.94: Nevus: Brown background and regular parallel longitudinal The irregular pattern points to malignancy (melanoma).
lines. This pattern consists in:
Fig. 9.95: Nevus: Brown background and regular parallel longitudinal Fig. 9.96: Nevus: Brown background and regular parallel longitudinal
lines. lines.
Fig. 9.97: Nevus: Brown background and regular parallel longitudinal Fig. 9.98: Nevus: Brown background and regular parallel longitudinal
lines. lines.
Fig. 9.99: Acral melanoma: Brown background with irregular pattern of Fig. 9.100: Acral melanoma: Brown background with irregular pattern
the overlying lines in their thickness, color, and spacing (arrows). of the overlying lines in their thickness, color, and spacing (arrows).
1 2
Fig. 9.101: Ethnic pigmentation: Clinical view (1-2) and dermoscopy Fig. 9.102: Drug-induced pigmentation: Regular gray lines.
view: regular gray lines.
•• Irregular spacing, width and coloration choose a longitudinal biopsy, were it necessary. When in
•• Loss of parallelism doubt, perform a biopsy.
•• Lines with different shade and width
•• Brown or black color points to melanocytic hyperplasia SUGGESTED READING
GRAY BACKGROUND of Dermoscopy. Milán: EDRA Medical Publishing & New
(FIGS. 9.101 AND 9.102) Media; 2000.
2000.
Regular Gray Lines Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina:
Observable in: Ediciones Journal; 2012.
Johr R, Stolz, W. Dermoscopy: An Illustrated Self-Assessment
•• Ungual lentigo Guide, 2nd edition. New York: Mc-Graw Hill Education; 2015.
•• Ethnic pigmentation Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials
•• Laugier-Hunziker syndrome (MOABT). New York: Elsevier Ltd; 2004.
•• Drug-induced pigmentation Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat
Consists in:
facultas wuv Universitätsverlag, Austria www.facultas.wuv.at
•• Regular spacing, width and coloration Lallas A. Dermoscopy in general dermatology. Dermatol Clin.
•• No loss of parallelism 2013;3:679-94.
•• All lines with the same shade and width Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea
•• Grey color points to epithelial hyperpigmentation with ciones Gráficas; 2009.
out melanocyte hyperplasia Taylor & Francis; 2005.
MICRO-HUTCHINSON SIGN copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
Company; 1996.
This refers to the pigmentation, observable only under Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
dermoscopy but invisible to the naked eye, of the cuticle American Academy of Dermatology; 1999.
corresponding to a melanonychia extension. This kind of Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
lesion is highly suspicious of melanoma.
New Media; 2001.
CONCLUSION Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
copy. USA: Blackwell Science; 1994.
Dermoscopy provides additional criteria to study nail pig Zalaudek I, Argenziano G, Giacomel, J. Dermoscopy of Non-
mentation. These criteria will help the dermatologist to pigmented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
DIAGNOSTIC
ALGORITHMS 10
Horacio A Cabo
“There are different methods to evaluate pigmented lesions, especially melanoma.
The method most frequently used by experts is pattern analysis.
Although this is the one with highest sensitivity and specificity,
the difference between all the methods is very low.
The most used in addition to the pattern analysis are ABCD rule, 7-point chek-list,
11-point check-list and 3-point check-list between others.”
Diagnostic Algorithms 249
There are different methods to evaluate pigmented lesions, PATTERN ANALYSIS

especially melanoma. The method most frequently used
(TABLE 10.1, FIGS. 10.1 AND 10.2)
by experts is pattern analysis. Although this is the one with
highest sensitivity and specificity, the difference between Pattern analysis is based on the qualitative assessment
all the methods is very low. During the internet Consen of several individual dermoscopic criteria. The difference
sus in 2000, all the methods proved to be equally useful. between benign and malignant growth patterns is deter
We are going to describe the most used ones. All these mined by the general appearance of the lesion and, in
algorithms have been elaborated on the basis of statistical detail, by some structures suggesting malignancy. There
studies (Graphs 10.1 and 10.2). fore, pattern analysis consists in the general and local
All these methods evaluate criteria and dermoscopic studies of pigmented lesions:
patterns that have already been described in other chap •• General features: They enable or not a preliminary and
ters, so here we will only describe the theoretical basis and quick analysis of a melanocytic lesion.
analyze an example of melanoma with each of the differ •• Local features: They enable the detailed analysis of a
ent algorithms. melanocytic lesion.
Graph 10.1: Diagnostic accuracy (%) for melanoma of 4 dermoscopic diagnostic methods.
Graph 10.2: Specificity (%) for melanoma of 4 dermoscopic diagnostic methods.

Analyzing the general features means identifying the •• Multicomponent pattern: This is a combination of
different structures that, because of repetition and cover three or more dermoscopic structures.
ing an important part of the lesion, are known as patterns •• Nonspecific pattern: Absence of definite dermoscopic
(Table 10.1): structures or criteria.
•• Reticular pattern: Pigment network covering most of a Analyzing the local features means analyzing the lesion
pigmented lesion in detail and identifying some of the following structures:
•• Globular pattern: Round or oval structures of differ •• Pigment network: Typical or atypical
ent sizes. They may be in different colors and shades •• Streaks or projections: Regular or irregular
(brown, gray, and black). •• Dots and globules: With regular or irregular distribution
•• Cobblestone pattern: Angulated globules resembling •• Blue–white veil
cobblestones, generally bigger than globules. •• Asymmetric pigmentation
•• Homogeneous pattern: Diffuse brown, gray, blue, or •• Regression structures
black pigmentation without the presence of any other •• Vascular structures with atypical pattern
criteria.
•• Starburst pattern: Pigmented lines in radial arrange CONCLUSION
ment from the edge of a pigmented lesion. With the study of the general and local features of a given
•• Parallel pattern: In palms and soles. Pigmentation lesion, it is possible to make a diagnosis.
may follow the ridges or the furrows.
ABCD RULE
Table 10.1: Pattern analysis. (TABLES 10.2 AND 10.3, FIG.10.3)
Global features Local features ABCD rule is very useful to check if a melanocytic lesion is
Reticular pattern Pigment network benign, suspicious, or malignant.
Globular pattern Streaks Through the use of a multiple variable analysis, it has
Cobblestone pattern Dots and globules been proved that there are four criteria (asymmetry, bor-
der, color, and different dermoscopic criteria) which are
Homogeneous pattern Blue-whitish veil
very important to recognize a malignant melanoma. In
Starburst pattern Regression structures
order to put them into practice, a system has been deve
Multicomponent pattern Vascular structures
loped that aims at calculating a total dermoscopy score
Unspecific pattern Negative pigment network (TDS) by means of a linear equation. Total dermos
Shiny white structures copy score enables the scoring of lesions regarding their
Fig. 10.1: Superficial spreading melanoma clinical image. Fig. 10.2: Superficial spreading melanoma (Fig. 10.1) evaluated by
pattern analysis.
Table 10.2: ABCD rule (Stolz).

• Asymmetry: in 0, 1, or 2 axes × 1.3
• Borders: 0–8 × 0.1
• Color: 1–6 × 0.5
ūū Red, black, white, dark brown, light brown, and blue gray
• Different structures: 1–5 × 0.5
ūū Pigment network, streaks, globules, dots, and structureless
areas:
<4.75: Benign melanocytic lesion
4.76–5.45: Suspicious lesion
>5.46: Melanoma
potential malignancy. Before applying this rule it is neces

Fig. 10.3: SSM (Fig. 10.1) evaluated by the ABCD dermoscopy rule.
sary to rule out, through the identification of special pat
(A: Asymmetry; B: Border; C: Color; D: Different structures; TDS: Total
terns, several melanocytic lesions, such as globular, papillo dermoscopy score.
matous, spindly cells (Reed), pigmented Spitz, congenital,
recurrent, and “agminado” nevi, as well as spilus nevi.
Each criterion is assigned a value and multiplied by of pigment at the periphery of the lesion or a gradual and
an established conversion factor, which yields the TDS, blurred border. Based on this analysis, lesions are divided
whose value indicates if the lesion is benign, suspicious, or into octaves. In this manner, the maximum score for the
malignant (Table 10.2). border is 8, and the minimum score is 0. From the origi
nal description of this rule it is evident that on occasion
Asymmetry (A) reproducibility is low and the score of the border or con
To judge asymmetry, the lesion is bisected along two axes tour only adds relevant information in very few lesions.
at 90°, positioned in such a way that they yield the lowest Thus, in most lesions, it is possible to omit border score
possible score. Asymmetry must be calculated according determination.
to the distribution of colors and structures on both sides
of these axes and not just by the contour, as happens in
the case of clinical ABCD rule. If there is no asymmetry
with reference to both axes, the score is 0. If there is asym
metry with reference to only one axis, the score is 1; and
in the case of asymmetry with reference to both axes, the
score is 2.
Color (C)
In order to determine the score for color, six hues can be
identified with a dermatoscope: white, red, light brown,
dark brown, blue-gray, and black. Four colors result from
melanin distribution (light and dark brown, due to mel
anin in the dermoepidermal junction; black, resulting
from melanin in the superior granular layer or stratum
corneum; and blue-gray, owing to melanin in the papillary
dermis). White is the consequence of regressive changes;
Border or Contour (B) and red is the consequence of inflammation or neovascu
Evaluation of the border or contour was established on larization. If the area is lighter than the adjacent normal
the basis of existence of either a sharp and abrupt ending skin, white is assigned to it. The values for color score go
Table 10.3: Additional criteria for malignancy.

Vascular pattern
Regression
Pseudopods
Table 10.4: 7-point checklist method (Argenziano).

• Major criteria (two point each)
ūū Atypical pigment network
ūū Blue-white veil
ūū Atypical vascular pattern
• Minor criteria (one point each)
ūū Irregular streaks
ūū Irregular dots and globules
ūū Irregular pigmentation Fig. 10.4: SSM (Fig. 10.1) evaluated by the 7-point checklist method.
(TDS: Total dermoscopy score).
ūū Regression structures
from 1 to 6. As in asymmetry, the dermatoscope reveals a 7-POINT CHECKLIST

color range wider than that observed with the naked eye.
(TABLE 10.4 AND FIG. 10.4)
The method of the 7-point checklist is a diagnostic algo
rithm that provides a quantitative scoring system and a
simplification in comparison to the classical pattern analy
sis, since fewer features need to be identified. Because of
its frequent association with melanoma, the features here
under described were selected:
•• Major criteria
–– Atypical pigment network
Different Structures (D) –– Blue-white veil
To assess the different dermoscopic structures, five main –– Atypical vascular pattern
features must be considered: structureless areas, pigment •• Minor criteria
network, streaks or projections (branched streaks), dots, –– Irregular streaks
and globules. –– Irregular dots and globules
–– Irregular pigmentation
ABCD Different Structures –– Regression structures
•• Pigment network The differences between melanomas and nevi have
•• Globulos been evaluated through a statistical test. Using probability
•• Dots percentages, calculated by means of a multiple variable
•• Streaks/branched streaks analysis, a score of 2 was assigned to three of the criteria
•• Structureless areas with probability quotients >5, known as “major criteria,”
If TDS falls within the benign or suspicious range, it is and a value of 1 to the four criteria with probability quo
necessary at any rate to check if the additional malignancy tients <5, known as “minor criteria.” By simply adding the
criteria are present. individual scores, it was determined that a score of 3 or
Three additional criteria have been identified: vascular more resulted in a melanoma diagnosis, with 95% sensibi
pattern, regression, and pseudopods (Table 10.3). lity and 75% specificity (Table 10.4).
Table 10.5: 3-point checklist (Soyer).

Definition:
Asymmetry: in shape and/or color on one or two perpendicular axes
Atypical pigment network: irregular spaces and thick lines
White–blue structures: structureless areas (fibrosis, melanosis, or
blue–gray globules)
The presence of two or more of these criteria points to a high
probability of melanoma.
Symmetry of Pattern
This feature refers to symmetry in all structures, including
color, along any axis crossing through the center of the
lesion. It does not require shape symmetry.
Fig. 10.5: SSM (Fig. 10.1) evaluated with the 11-point checklist method.
Single Color
The recorded colors are black, gray, blue, red, dark brown,
and tan; white color is ignored. A single coloration excludes
a melanoma diagnosis.
Positive Features
At least one of the following features must be present:
•• Blue-white veil
•• Multiple brown dots
•• Streaks or radial streaming
•• Pseudopods
•• Scar-like whitish areas (regression)
•• Peripheral black dots/globules
•• Multiple colors (five or six colors)
•• Multiple blue or gray dots
•• Atypical pigment network
Fig. 10.6: SSM (Fig. 10.1) evaluated with the 3-point checklist method.
3-POINT CHECKLIST METHOD

11-POINT CHECKLIST METHOD (FIG. 10.5) (TABLE 10.5 AND FIG. 10.6)
This method has 92% sensibility and 71% specificity This method was devised for inexperienced dermoscop
regarding melanoma diagnosis. This method works with ists (general practitioners, pediatricians, or beginner
positive and negative criteria or features. For a melanoma dermatologists) with a view to helping them make accu
diagnosis, the negative criteria, with very low melanoma rate diagnoses of melanomas while developing their skills.
sensibility, must be absent, while at least one of the posi- It was devised as a screening approach, which means that
tive criteria must be present. it is much more sensitive than specific. In this manner, the
possibility of missing a melanoma is avoided.
Negative Features It is an algorithm based on a simplified dermoscopic
These are two features, lesion symmetry (symmetry of pat pattern, very useful to interpret, if a suspicious lesion must
tern) and single color, which must be absent. be excised.
Based on the results of the Dermoscopy Consensus atypical melanocytic nevi from thin melanomas. J Am Acad
Meeting of 2001, it was shown that there are three espe Dermatol. 2007;56:759-67.
cially important criteria in order to make a diagnosis when Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of pig
mented skin lesions: results of a consensus meeting via the
assessing cutaneous pigmented lesions and, particularly,
Internet. J Am Acad Dermatol. 2003;48(5):679-93.
to differentiate benign pigmented lesions from melanoma.
These three criteria are asymmetry, atypical pigment of Dermoscopy. Milán: EDRA Medical Publishing & New
network, and the presence of blue-white structures. In fact, Media; 2000.
these are the three points evaluated in this rule. Cabo H. Dermatoscopia. Buenos Aires, Argentina: Weber Ferro; 2000.
Color and/or structure asymmetry may locate on one Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina:
or two perpendicular axes. The blue-white structures cor Ediciones Journal; 2012.
respond to any shade of blue and/or white (a combination Jorh R, Soyer P, Argenziano G, et al. Dermoscopy. The Essentials
of the early changes of the blue-white veil and regression (MOABT). New York: Elsevier Ltd; 2004.
structures). Sensitivity for skin cancer (melanoma and
basal cell carcinoma) was 91% and specificity was 71.9%.
The three-point checklist is a simple, feasible, accurate, tern Analysis 2011 Facultas Verlags- und Buchhandels AG
and reproducible method, which renders it an effective facultas wuv Universitätsverlag, Austria www.facultas.wuv.at
tool in skin cancer detection. Lallas A. Dermoscopy in general dermatology. Dermatol Clin.
The presence of more than one criterion suggests that a 2013;3:679-94.
lesion is suspicious. In general, only one criterion is found Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea
in early melanoma. Two criteria are found in melanoma ciones Gráficas; 2009.
and pigmented basal cell carcinoma. Therefore, excision is Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:
recommended for lesions with two or three positive points.
The advantage of this rule lies in its simplicity and its copy of Pigmented Skin Lesions. Sydney: McGraw-Hill Book
easy acquisition. By using it, it is possible to reach sensibility Company; 1996.
and specificity percentages for cancer detection compa Rabinovitz H, Kopf A. Dermoscopy: A Practical Guide. Miami:
rable to those of the other algorithms that require higher American Academy of Dermatology; 1999.
training (Table 10.5). Soyer P, Argenziano G, Chimenti S, et al. Dermoscopy of Pig
SUGGESTED READING New Media; 2001.
Annesi G, Bono R, Sampogna F, et al. Sensitivity, specificity, and Stolz W, Braun-Falco O, Bilek P, et al. Color Atlas of Dermatos
diagnostic accuracy of three dermoscopic algorithmic meth copy. USA: Blackwell Science; 1994.
ods in the diagnosis of doubtful melanocytic lesions: the Zalaudek I, Argenziano G, Giacomel J. Dermoscopy of Non-Pig
importance of light brown structureless areas in differentiating mented Skin Tumors. Boca Raton, FL: CRC Press; 2016.
TOTAL-BODY
PHOTOGRAPHY AND
SEQUENTIAL DIGITAL 11
DERMOSCOPY IMAGES
Gabriel Salerni
“Melanoma may be not only clinically but also dermoscopically
indistinguishable from benign melanocytic lesions, especially in early stages.
The overlap of dermoscopic criteria for melanoma and atypical nevi
may lead to overlook melanomas and to excise a large number of benign lesions.
Benign melanocytic lesions are usually stable, while melanomas tend
to evolve and undergo changes over time, which are initially microscopic.
Thus, comparison of sequential dermoscopy images of atypical melanocytic
lesions has been proposed as a strategy to recognize incipient melanomas
that may lack distinctive dermoscopic features“
Total-Body Photography and Sequential Digital Dermoscopy Images 257
Melanoma may be not only clinically but also dermoscopi- FOLLOW-UP STRATEGY
cally indistinguishable from benign melanocytic lesions,1-3
especially in early stages. The overlap of dermoscopic cri- The technique of digital dermoscopy follow-up includes
teria for melanoma and atypical nevi may lead to overlook two approaches: short-term follow-up and medium/long-
melanomas and to excise a large number of benign lesions. term follow-up.
Benign melanocytic lesions are usually stable, while Short-term follow-up, usually in a period of 3 months,
melanomas tend to evolve and undergo changes over is used to make a clinical judgment on suspicious melano-
time, which are initially microscopic. Thus, comparison cytic lesions that are lack of specific dermoscopic criteria
of sequential dermoscopy images of atypical melanocytic for melanoma.5,6 In short-term follow-up, any significant
lesions has been proposed as a strategy to recognize incip- morphological change requires the excision of the lesion.
ient melanomas that may lack distinctive dermoscopic Medium/long-term follow-up allows for the compari-
features (Fig. 11.1).1 son of atypical nevi during standard periods, usually from
The use of sequential dermoscopy images allows for an 6 to 12 months.7-9 This technique is generally restricted
objective comparative analysis, which helps in the iden- to patients with large numbers of atypical melanocytic
tification of subtle changes, otherwise not visible, adding lesions.
useful information for the differentiation of early melano- Both short- and medium/long-term follow-ups have
mas from benign melanocytic lesions. In a recent study,4 demonstrated the improvement in the detection of mel-
melanomas diagnosed in patients enrolled in the digital anomas with low index of suspicion, which can only be
follow-up program in a melanoma unit were compared detected due to dermoscopic changes.2
with those diagnosed in patients referred for assessment
with clinical suspicion of melanomas. It was demonstrated CRITERIA FOR LESIONS SELECTION
that melanomas diagnosed in patients under digital fol-
Establishing which lesions are candidates for digital der-
low-up program had a low index of suspicion not only in
moscopy follow-up is a key requirement. These lesions
the clinical but also in the dermoscopical evaluation (with
should be those showing mild to moderate clinical and/
almost 40% misclassified as benign according to the der-
or dermoscopical atypia. Suspicious lesions showing der-
moscopic diagnostic algorithms).
moscopic criteria for melanoma should be excised and
submit for histopathology. Moreover, follow-up of lesions
EQUIPMENT with clear-cut criteria for benignity is not justified in terms
Several systems that allow for the record of clinical and of cost efficiency.
dermoscopical images of skin lesions are currently avail-
able. These devices consist in a video and/or a photo SIGNIFICANT CHANGES DURING
camera adapted for dermoscopy, which is connected to a DIGITAL FOLLOW-UP
computer with special software for the storage and com-
parative analysis of sequential dermoscopy images. Significant changes during sequential dermoscopy have
Briefly, digital dermoscopy devices allow for the record been defined by Kittler et al.15 and adopted by different
of images by assigning a number and additional infor- working groups in ulterior studies. Significant changes
mation such as location or other data of interest. More are as follow: (1) asymmetric enlargement; (2) changes
complex devices also allow for the total-body photograph in dermoscopic structures (expansion or decrease of pig-
registries or body mapping, which enables both the iden- ment network; variation in the distribution or the num-
tification of the exact location of the lesions and the detec- ber of dots/globules; modification of depigmented areas
tion of new lesions by side-by-side comparison. The use of or regression structures; appearance of streaks, scar-like
the latter is of radical importance in the management of areas, blue-whitish veil, and atypical vessels); (3) increase
patients with large numbers of melanocytic lesions, pro- in the number of colors; (4) regression features affecting
viding uniformity to the procedure and making the com- >50% of the lesion; and (5) focal pigment modifications
parative analysis more reliable and objective. (Figs. 11.2A to I). In a recent study,20 all types of changes
Fig. 11.1: Stable melanocytic lesions in a patient with a personal and familial history of melanoma. Although the lesions display signs of
dermoscopic atypia, none has the criteria of malignancy.
A B
C D
E F G
H I
Figs. 11.2A to I: Melanomas detected due to changes during digital follow-up. (A and B) In situ melanoma in the back of a 63-year-old man,
with atypical mole syndrome; the lesion showed asymmetric enlargement over a period of 9 months. (C and D) In situ melanoma in the leg of
a 54-year-old woman, with a personal history of melanoma; asymmetric enlargement, changes in dermoscopic structures and focal pigment
changes were observed after 18 months. (E to G) In situ melanoma detected due to asymmetric enlargement over a period of 20 months in the
leg of a 36-year-old woman, carrier of mutation G101W in CDKN2A, a personal history of multiple melanoma and familial melanoma. (H and I)
Invasive melanoma (Breslow 0.35 mm) in the back of a 65-year-old woman with a personal and a familial history of melanoma; the lesion showed
regression features after 6 months.
considered significant during digital follow-up were more visit. Thus, through the comparative analysis of body map-
common in melanoma than in nevi. It was found that focal ping, one can objectively determine the appearance of
pigment changes and focal changes in the structure were new lesions during the follow-up and, by comparing der-
significantly more common in melanoma than in nevi moscopy records, detect microscopic changes, not visible
(with an odds ratio of 2.98 and 5.47, respectively), but no to the naked eye in lesions selected for monitoring.
statistically significant differences were observed in terms The baseline examinations consist of two steps: the
of asymmetric enlargement, regression, or changes in the first step is total-body photography, for clinical examina-
number of colors. In the same study, over a period of 10 tion of the patient and body mapping; and the second step
years, 53 lesions were excised only due to symmetrical is digital dermoscopy, for clinical and dermoscopic exami
enlargement, a type of change that is considered not sig- nations in real time of all individual lesions. Digital storage
nificant. Among these lesions, it was diagnosed one mel- of dermoscopy images of each lesion showing atypical fea-
anoma, Breslow 0.5 mm, which was classified as benign tures is performed.
according to the ABCD rule of dermoscopy. Kittler et al.15 The follow-up examinations include two steps: the
reported that a melanoma initially diagnosed as an atyp- first step is body mapping, for comparison of total-body
ical nevus only showed symmetrical growth without der- images with previous registries to detect any changes in
moscopic structural modifications; the authors concluded shape, color, or surface eventually occurring in any pig-
that all atypical nevi with substantial changes in follow-up mented skin lesions, and for identification of new lesions;
should be excised in order to not overlook a melanoma. and the second step is sequential digital dermoscopy, for
the dermoscopic comparison and storage of lesions with
atypical features, and for the clinical and dermoscopic
TOTAL-BODY PHOTOGRAPHY—
examinations of eventual new lesions not previously reg-
BODY MAPPING istered.
The detection of new or changing lesions in high-risk The “two-step method of digital follow-up”7 has been
patients is difficult, especially in those patients with large proposed as an approach for the assessment of individuals
numbers of melanocytic nevi, unless total-body photo- at high risk, being potentially more accurate than the two
graphs are available for comparison.21 strategies separately. A recent series of studies8,20 analyzed
Body mapping consists in the standardized record of the 10-year experience of follow-up with total-body pho-
body images in different positions in order to cover the tography and sequential digital dermoscopy in a unit mel-
entire body surface; these images are stored for the com- anoma, the authors found that almost 40% of melanomas
parative study in successive controls (Figs. 11.3A to L). It diagnosed in patients under surveillance corresponded
is used in patients at high risk for melanoma, usually in to new lesions detected by the comparison of body maps,
the context of multiple dysplastic nevi, multiple nevi, prior or lesions that are already present have not been initially
melanoma, familial melanoma, or a history of multiple considered for follow-up with dermoscopy.
primary melanomas.22-24
It has been suggested that a monitoring strategy that BENEFITS OF DIGITAL FOLLOW-UP
focuses solely on sequential digital dermoscopy of those
In the last years, multiple studies have shown the bene-
atypical nevi registered in a first visit will probably over-
fits of monitoring high-risk patients with sequential digital
look melanomas that arise as new lesions or correspond-
dermoscopy, basically, the early diagnosis of melanoma
ing to lesions that have not been considered for follow-up
with a low rate of excisions.7-20
initially.9,25
Of the 98 melanomas diagnosed over 10 years using
the “two-step method of digital follow-up” in the mela-
TOTAL-BODY PHOTOGRAPHY AND noma unit of the Hospital Clinic in Barcelona, Spain,8 53
DIGITAL DERMATOSCOPY (TWO-STEP melanomas were in situ, and the rest 45 invasive melano-
mas corresponded entirely to stage IA. These findings are
METHOD OF DIGITAL FOLLOW-UP)
consistent with those from the main working groups in
The “two-step method of digital follow-up”7 consists of this issue. Fuller et al.9 reported six melanomas diagnosed
the combined use of total-body photographs and sequen- during follow-up (although only one was diagnosed due
tial digital dermoscopy images of atypical lesions in every to dermoscopic changes); two were in situ and the tumor
A B C
D E F
G H I
J K L
Figs. 11.3A to L: Body mapping comparison of the trunk of a 20-year-old patient with atypical mole syndrome and a familial history of melanoma
over a period of 3 years.
thickness of invasive melanomas ranged between 0.23 were reported by Menzies et al.5 who diagnosed five in
and 0.35 mm. Bauer et al.12 diagnosed two melanomas, situ and two invasive melanomas (0.25 and 0.28 mm). In
and Robinson and Nickoloff13 diagnosed four melanomas, 2002, Malvehy and Puig7 reported eight melanomas diag-
all in situ. In 2000, Kittler et al.16 diagnosed eight melano- nosed during follow-up, of which two were in situ and six
mas during follow-up, five in situ, and the rest three inva- invasive with a tumor thickness of <0.75 mm. Argenziano
sive with a tumor thickness of <0.75 mm. Similar results et al.17 diagnosed 12 melanomas in their study, 6 in situ
and 6 invasive with a mean tumor thickness of 0.52 mm.

Altamura et al.,6 in 2008, reported 81 digital melanomas
diagnosed during follow-up, 55 in situ and the rest 26 inva-
sive, all with a tumor thickness of <1 mm. Haenssle et al.
reported their experience over 10 years in monitoring
patients at risk for melanoma with digital dermoscopy;14,18
87 melanomas were detected during follow-up, 38 were in
situ, and 49 invasive, with a mean thickness of 0.57 mm.
According to these publications, more than half of mela
nomas diagnosed during follow-up were in situ, and
among invasive none had a thickness of >1 mm, confirm-
ing that sequential digital dermoscopy is an effective strat-
egy for early diagnosis.
In late 2012, a meta-analysis of sequential digital der-
moscopy was published on behalf of the International
Dermoscopy Society.26 This analysis showed that moni-
toring melanocytic lesions with sequential digital dermos-
copy allows for the detection of incipient melanomas with
a low rate of excisions. With this approach, the proportion
of in situ and thin melanomas are higher than expected in
general population. It was also demonstrated that chances
to detect a melanoma during surveillance increase as the
length of follow-up extends, so surveillance must be main- Fig. 11.4: Patient eligible for digital follow-up. The patient has a per-
tained over time in high-risk population. sonal history of melanoma and atypical mole syndrome, with large
numbers of melanocytic lesions, both typical and atypical.
INDICATIONS OF DIGITAL FOLLOW-UP

Already in 2007, Carli questioned the use of sequential In a recent study,8 12.6% of the patients included in the
digital dermoscopy in terms of cost effectiveness; high- digital dermoscopy follow-up program (approximately
lighting the overwhelming burden that digital follow-up one out of seven) were diagnosed with a new melanoma
implicates.27 during surveillance. Furthermore, the percentage of
Chances of success in digital follow-up depend mainly patients who were diagnosed with melanoma during fol-
on the proper selection of patients. Even though any patient low-up increased from 7% in patients without a history of
can benefit from this approach, the fact that it is time con- melanoma to 18% and 23% in patients with a history of sin-
suming and expensive in terms of training and equipment gle and multiple primary melanomas, respectively, prior
makes its use justified only in individuals at high risk for to the beginning of monitoring. This implies that includ-
melanoma (Fig. 11.4). The presence of large numbers of ing only patients at high risk of developing melanoma is a
melanocytic lesions, both clinical and atypical nevi, is key requirement, since melanoma incidence among these
associated with a risk of melanoma 7–10 times higher than patients was almost 1,500 times higher than the normal
general population.28-30 Although some nevi may be mela- population.
noma precursors, they are mostly markers of an increased
risk.30 History of previous melanoma is associated with an
increased risk of a second primary melanoma.28,29 Patients
LIMITATIONS
with a strong familial history of melanoma and multiple Sequential digital dermoscopy is a reliable strategy for the
clinically atypical nevi represent the population at highest care of patients at high risk for melanoma, and its use is rec-
risk for melanoma (35–1,000 times).28,29 In the context of ommended in the main worldwide clinical guidelines for
these families, the presence of mutations in CDKN2A and the recognition of early melanomas without specific der-
CDK4 genes implies a disease penetrance from 35% to 90% moscopic features. However, this technique does not lack
at the age of 80, depending on the country.31 limitations, and some points are worthy of consideration.
The possibility of monitoring may lead to choose a suspi- digital follow-up”) in the early diagnosis of melanoma in
cious lesion that should be removed. Facing the decision high-risk patients. J Am Acad Dermatol. 2012;67(1):e17-27.
9. Fuller SR, Bowen GM, Tanner B, et al. Digital dermoscopic
to follow-up, the patient might not attend to the next con-
monitoring of atypical nevi in patients at risk for melanoma.
trol with the consequent risk that a lesion, which could be Dermatol Surg. 2007;33:1198-206.
a melanoma, is not removed promptly. The indiscriminate 10. Schiffner R, Schiffner-Rohe J, Landthaler M, et al. Long-
use of image registries is not recommended, since the term dermoscopic follow-up of melanocytic naevi: clin-
utility of this strategy depends on the physician’s experi- ical outcome and patient compliance. Br J Dermatol.
2003;149:79-86.
ence in the interpretation of the images (it is basically an
11. Haenssle HA, Krueger U, Vente C, et al. Results from an
operator-dependent technique) and compliance by the observational trial: digital epiluminescence microscopy
patient. follow-up of atypical nevi increases the sensitivity and the
chance of success of conventional dermoscopy in detecting
melanoma. J Invest Dermatol. 2006;126:980-5.
CONCLUSION 12. Bauer J, Blum A, Strohhacker U, et al. Surveillance of
The inclusion of patients who are at high risk for mela- patients at high risk for cutaneous malignant melanoma
using digital dermoscopy. Br J Dermatol. 2005;152:87-92.
noma in follow-up programs with digital dermoscopy has
13. Robinson JK, Nickoloff BJ. Digital epiluminescence micros-
proven to be a useful approach in early melanoma detec- copy monitoring of high-risk patients. Arch Dermatol.
tion, enabling the diagnosis of lesions with a low rate of 2004;140:49-56.
suspicious not only clinically but also dermoscopically, 14. Haenssle HA, Korpas B, Hansen-Hagge C, et al. Selection of
while minimizing the excision of benign lesions. The patients for long-term surveillance with digital dermoscopy
by assessment of melanoma risk factors. Arch Dermatol.
chances of success during follow-up depend mainly on
2010;146:257-64.
the proper selection of patients and lesions to monitor. 15. Kittler H, Pehamberger H, Wolff K, et al. Follow-up of
Experience in the interpretation of the images by the phy- melanocytic skin lesions with digital epiluminescence
sician and patient compliance are key requirements. microscopy: patterns of modifications observed in early
melanoma, atypical nevi, and common nevi. J Am Acad
Dermatol. 2000;43:467-76.
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monitoring of nevi in similar patient populations at risk factors for cutaneous melanoma: III. Family history, actinic
for cutaneous melanoma. Dermatol Surg. 2010;36(7): damage and phenotypic factors. Eur J Cancer. 2005;41:
1087-98. 2040-59.
26. Salerni G, Terán T, Puig S, et al. Meta-analysis of digital der- 30. Cho E, Rosner BA, Feskanich D, et al. Risk factors and indi-
vidual probabilities of melanoma for whites. J Clin Oncol.
moscopy follow-up of melanocytic skin lesions: a study on 2005;23:2669-75.
behalf of the international dermoscopy society. J Eur Acad 31. Tsao H, Atkins MB, Sober A. Management of cutaneous mel-
Dermatol Venereol. 2013;27(7):805-14. anoma. N Engl J Med. 2004;351:998-1012.
REVISED PATTERN
ANALYSIS 12
Cliff Rosendahl, Harald Kittler
“Revised pattern analysis is a stepwise algorithmic method for the diagnosis of pigmented skin lesions,
pigmented by melanin, significant blood pigment (as in structureless blood or red clots), or discolored
keratin. The method of pattern analysis was first published in 1987 and no method has since been shown
to be more accurate, but there was no stepwise process and the language of dermatoscopy evolved with
a myriad of poorly defined or undefined metaphorical terms that in many cases carried preconceived
diagnostic implications.
Revised pattern analysis uses a limited number of clearly defined geometric terms and provides a
clear stepwise process of analysis, assessing patterns then colors and finally clues, leading the clinician
to a specific provisional diagnosis or alternatively a limited differential diagnosis. “
Revised Pattern Analysis 267
Revised pattern analysis (RPA) is a stepwise algorithmic •• A clod is a well-defined, solid object larger than a dot
method for the diagnosis of pigmented skin lesions, and it can be of any color and any shape.
pigmented by melanin, significant blood pigment (as in •• A dot is an object too small to have a discernable shape
structureless blood or red clods), or discolored keratin.1,2 (at 10 times magnification).
The method of pattern analysis was first published in 1987 •• A structureless area is an area covering a significant
by Pehamberger et al.3 and no method has since been portion of a lesion with no basic structure predomi-
shown to be more accurate, but there was no stepwise nating.
process and the language of dermatoscopy evolved with A pattern is formed by multiple repetitions of a basic
a myriad of poorly defined or undefined metaphorical structure and it must cover a significant portion of a lesion
terms that in many cases carried preconceived diagnostic to be regarded as a pattern. For example, a few lines
covering 5–10% of a lesion with an otherwise structureless
implications. Revised pattern analysis uses a limited
pattern would constitute a clue rather than a pattern. If
number of clearly defined geometric terms and provides a
however reticular lines covered 30% of an otherwise struc-
clear stepwise process of analysis, assessing patterns then
tureless lesion, then the lesion would be regarded as having
colors and finally clues, leading the clinician to a specific
two patterns (Fig. 12.2). In Figure 12.2, the right-hand side
provisional diagnosis or alternatively a limited differential
of the lesion has a pattern of lines reticular. There are a few
diagnosis (Fig. 12.1).
lines and dots on the left side but as none of these struc-
In the language of RPA, there are five basic structures:
tures predominate, this portion of the lesion is termed
lines, pseudopods, circles, clods, and dots (Fig. 12.1, ver- structureless. Note that structureless does not necessarily
tical). Because lines are a very specific structure, they equate with featureless.
are further subdivided into five different types: reticular, Patterns should be assessed as such and a few struc-
branched, parallel, radial, and curved (Fig. 12.1, horizon- tures out of synchrony do not destroy a pattern. For example,
tal). A pattern is an area made up of multiple repetitions of looking at the right side of Figure 12.2 you may recognize a
a basic structure. The terms used are clearly defined: few circles but that does not interfere with the description
•• A line is a structure with length greatly exceeding width. of a pattern of reticular lines. It must be remembered that
•• A pseudopod is a line with a bulbous end. we are describing biological material rather than an archi-
•• A circle is a curved line sensibly equidistant from a tect’s design and it is appropriate to tolerate reasonable
central point (this includes ellipses). variation.
Fig. 12.1: There are five basic structures in revised pattern analysis: Fig. 12.2: A pigmented skin lesion with a pattern of lines reticular on
Lines (A: Reticular; B: Branched; C: Parallel; D: Radial; and E: Curved), the right. Although there are some lines and dots on the left, none of
pseudopods, circles, clods, and dots. these predominate so the pattern is structureless. This is a solar lentigo
on the right-hand side in collision with a pigmented squamous cell
carcinoma on the left-hand side.
WHY THE TWO-STEP METHOD OF

DERMATOSCOPY IS NOT USED IN
REVISED PATTERN ANALYSIS
The two-step method of dermatoscopy requires that mela-
nocytic status be determined by dermatoscopy as a first
step before the lesion is assessed for clues to melanoma
as a second step.4,5 The so-called melanocytic criteria
(network, pseudonetwork, aggregated brown globules,
radial streaming, pseudopods, homogeneous blue pig-
mentation, and parallel ridge pattern) are not melanocytic
criteria at all. They are just melanotic criteria and can occur
in any pigmented lesion whether it has a proliferation of
melanocytes or not. The lesion in Figure 12.2 has clear Fig. 12.3: The three basic steps in revised pattern analysis: a stepwise
pigment network but it is a solar lentigo in collision with assessment of patterns, colors, and clues.
a pigmented squamous cell carcinoma (pSCC) in situ,
neither of which are melanocytic. The so-called pseudo-
network is commonly seen in solar lentigo and pigmented
actinic keratosis (pAK), neither of which are melanocytic. determine the stepwise assessment. The primary pattern is
Lines radial segmental are seen in a basal cell carcinoma the first pattern encountered in the order lines (reticular,
(BCC) (see Fig. 12.20) and in SCC in situ (see Fig. 12.22), branched, parallel, radial, and curved), pseudopods, circles,
neither of which are melanocytic. The sensitivity and clods, dots, and structureless, regardless of whether it is
specificity of the first step of the two-step process were the pattern that covers the greatest area.
evaluated in a study on consecutive lesion in a practice in Step 2: After deciding what pattern is present, or in the case
Europe, compared to a practice in Australia.6 The specificity that there is more than one pattern—what the primary pat-
was found to be 67.9% in Europe and 33.6% in Australia. tern is—a decision must be made as to whether the lesion
is symmetrical or not. Symmetry is decided on the basis of
structure and color, regardless of the shape.
APPLYING REVISED PATTERN ANALYSIS
In the case of only one pattern, symmetry is decided
The three fundamental steps in pattern analysis—patterns, on the basis of color. If there is one pattern and one color,
colors, and clues—are shown in Figure 12.3.2 then by definition the lesion is symmetrical. If there is one
Before RPA is applied, a lesion must be identified as pattern but more than one color and the colors are com-
pigmented. Although pigmentation may be obvious, it is bined asymmetrically, the lesion is asymmetrical (Fig. 12.4).
important to understand that the presence of any visible In Figure 12.4, the lesion on the left has a pattern of
pigment at all should, as a rule, lead to the lesion being yellow clods. There is one pattern and one color. The
assessed as a pigmented lesion. Pigmented structures are background does not constitute a structureless pattern
far more specific as diagnostic clues than nonpigmented because it is overlaid by the pattern of yellow clods. A cou-
structures such as blood vessels, and should always be ple of white clods have no impact on the pattern although
given priority when present.1 they are additional clues to the diagnosis of seborrheic
Step 1: Once a lesion is recognized as pigmented, the first keratosis. With one pattern and one color the lesion is
step is to assess the pattern(s) with a decision made as to symmetrical.
whether there is one pattern or more than one pattern. In the case of more than one pattern, symmetry is
Defining a precise number of patterns does not addition- determined by the structures, and color is disregarded in
ally assist the diagnostic process and so the simple decision the assessment of symmetry (Fig. 12.3). The lesion in the
on whether there is one pattern or more than one is ade- right of Figure 12.4 has two patterns, a central structureless
quate. In the case of one pattern, the assessment pro- pattern and peripheral clods combined symmetrically in a
ceeds in a stepwise fashion, which will be described, and concentric arrangement. It does not matter that there are
if there is more than one pattern, the primary pattern will a few clods missing at the top. Such variation is acceptable
Fig. 12.4: The lesion on the left has one pattern clods and one color yellow. By definition, it is symmetrical. The lesion on the right has two
patterns: central structureless and peripheral clods, combined in a symmetrical concentric pattern.
in biological tissue. Another way of understanding this is USING THE AIDE MEMOIRE
to realize that such a degree of variation is not consistent
FOR REVISED PATTERN
with the disorganized behavior of malignant tissue.
Step 3: Having assessed the patterns and symmetry of a ANALYSIS
pigmented skin lesion, RPA then proceeds in a stepwise
fashion according to clues (see Fig. 12.3). This stepwise Using the aide memoire presented in Figure 12.7, the
process is illustrated for lesions with one pattern, clods, lesions relevant to pattern analysis have been conve-
in Figure 12.5 and with more than one pattern including a niently subdivided into just six groups.
primary pattern of clods in Figure 12.6. The sixth group includes lesions pigmented by pigments
other than melanin and only needs to be considered when
AN AIDE MEMOIRE FOR REVISED that is evident.
PATTERN ANALYSIS The fifth group is for dermatofibroma (DF) and its
inclusion ensures that this diagnosis is considered even
This stepwise process permits assessment of lesions in a when not obvious. The diagnosis of DF can usually be
logical progression starting with an assessment of the
confirmed confidently by a symmetrical combination of
patterns, colors, and finally the clues (see Fig. 12.3). Pat-
virtually any dermoscopic pattern peripherally combined
terns and colors are assessed as if from a distance, actually
with a central hypopigmented structureless area. Com-
avoiding attention to subtle details, and when that assess-
monly, polarizing-specific white lines are seen in the cen-
ment discovers biological symmetry, the likelihood of
tral hypopigmented area. A history of stability of a clinical
malignancy is very low. On the other hand, the discovery
palpable nodule that characteristically retracts when the
of patterns and/or colors combined asymmetrically raises
the possibility of malignancy and should lead to a careful lesion is laterally compressed is usually compelling addi-
examination for clues that may support that suspicion. tional support for the diagnosis of DF.
Such an assessment can proceed in the stepwise manner Considering that the groups “DF” and “other” gener-
illustrated for the pattern of clods in Figure 12.5 or 12.6. ally do not provide a diagnostic challenge, the applica-
Alternatively, a simpler method should use the primary tion of RPA can concentrate primarily on the use of clues
pattern to provide a limited differential diagnosis that is to establish a provisional diagnosis of lesions in the first
then sorted according to specific clues to the defined alter- four categories defined in the RPA aide memoire: melano-
natives. This simplified approach is presented as an “Aide cytic lesions, benign keratinocytic lesions, BCC, and SCC
Memoire” for RPA (Fig. 12.7). including AK and SCC in situ (Fig. 12.8).
Fig. 12.5: The stepwise assessment of clues in lesions with one pattern, clods.
Fig. 12.6: The stepwise assessment of clues in lesions with a primary pattern of clods combined with any secondary pattern (dots or structureless).
Fig. 12.7: The use of an aide memoire to provide a limited list of diagnostic categories in revised pattern analysis. The patterns are listed in order
of specificity and the list of categories is smaller for more specific patterns. A lesion is examined for patterns and the first pattern encountered
in the order shown above is the primary pattern. The differential diagnosis will be limited to the categories populated for that primary pattern.
(LPLK: Lichen planus like keratosis; pBCC: Pigmented basal cell carcinoma; pSCC: Pigmented squamous cell carcinoma; DF: Dermatofibroma; Seb
K: Seborrheic keratosis; pAK: Pigmented actinic keratosis; Kaposi: Kaposi’s sacrcoma).
A lesion with one pattern, lines reticular/branched,

or a lesion with more than one pattern but with a primary
pattern of lines reticular/branched, and which is not an
accessory nipple or DF will be limited to only two catego-
ries: melanocytic or benign keratinocytic.
A lesion with one pattern, thin lines reticular and one
color, brown can be either a solar lentigo or a Clark nevus.
A solar lentigo may have the clues of a sharply demarcated
(abrupt) scalloped border whereas a Clark nevus usually
has a gradual border over the entire periphery without
scalloped areas. In reality, the distinction cannot always
be made. This must be acknowledged as a limitation of the
Fig. 12.8: This lesion had more than one pattern—structureless
centrally and lines reticular (or circles—such variations of perception
method but as both lesions are benign, it has no relevance
do no alter the outcome of revised pattern analysis) peripherally, with to any necessity of a biopsy.
asymmetry produced by a small eccentric structureless gray area If the reticular lines are thick and brown, then superfi-
superiorly, and the additional clue to malignancy of polarizing-specific cial congenital nevus and early seborrheic keratosis can be
white lines (left). Palpation and lateral compression by squeezing
suggested the diagnosis of dermatofibroma that was consistent with considered along with Clark nevus.
a history of stability over >20 years. If the lines are black, this is consistent with ink-spot
lentigo with additional clues being branched as well as
reticular lines and a very abrupt border.
THE PATTERN OF LINES RETICULAR OR A symmetrical lesion with only reticular lines but more
than one color can be a solar lentigo (clues as described
BRANCHED above, seborrheic keratosis (clues of multiple white
Lines reticular and branched are very similar and while the clods, multiple orange/yellow clods, well demarcated
presence of branched lines can be a useful clue to ink-spot border, thick curved lines and vessels as loops, or coils),
lentigo, as patterns, the two will be considered together. Clark nevus (clues as above), congenital nevus or in situ
melanoma (clues including an asymmetrical combina- absorbs all light and, therefore, it appears black at the level
tion of the colors, gray or blue structures, eccentric struc- of the stratum corneum. At the dermoepidermal junc-
tureless area other than skin colored, thick reticular lines, tion and the epidermis, the normal location of melanin in
peripheral black dots/clods, segmental radial lines/pseu- healthy skin, some light is reflected back by cells in the epi-
dopods, white lines, polymorphous vessels, or polygons. dermis so it appears near-black, which is brown. Because
A symmetrical reticular-pattern lesion with a darker of the fact that the collagen particles of the dermis scatter
center is most likely a Clark nevus. If the colors are com- back short wavelength (blue) light preferentially to long
bined in a variegate pattern and there are no clues to wavelength (red) light, while blocking the color of heme
melanoma then it is likely to be either a Clark nevus or a from below, melanin in the superficial and deep dermis
congenital nevus. If one or more of the clues to melanoma appears gray and black, respectively.
mentioned above are present, this diagnosis must be seri- Gray or blue structures correlate with melanin in the
ously considered. superficial and deep dermis, respectively. In melanomas,
A symmetrical reticular-pattern lesion with hyperpig- blue correlates with immature nested pigmented melano-
mentation peripherally can be a Clark nevus or a mela- cytes in the deep dermis, and in an asymmetrical lesion it
noma (if a clue to a melanoma is present). is a strong clue to invasive melanoma. In melanomas, gray
A lesion with a primary pattern of lines reticular/ dots usually correlate with melanophages in the papillary
branched can be combined with any of the other patterns dermis and they are a common finding in the majority of
(lines parallel, radial, or curved; pseudopods; circles; clods; in situ melanomas as well as being common in invasive
dots; or structureless) and if the combination is symmetri- melanomas.
cal for practical purposes there are five combinations to An eccentric structureless area must cover a sufficient
consider. First, a pattern with central clods and peripheral portion of the lesion to form a pattern; it must be con-
reticular lines is most consistent with a congenital or more trasted to a structured pattern within the lesion and it
rarely a Clark nevus. Second, a lesion with central reticular must be a color other than skin colored. In melanomas, if
lines and peripheral clods/dots will be a growing nevus, colored with the colors of melanin, it is produced by the
either Clark or congenital. Third, reticular lines and clods/ chaotic behavior of malignant melanocytes; if pink, it is
dots combined in a variegate pattern can be seen in either caused by increased blood flow; and if white, it may cor-
Clark or congenital nevus. Fourth, a peripheral reticular relate with fibrosis after regression.
pattern can be combined with a central structureless pat- Thick lines reticular are defined when the lines are
tern. In this case, a skin colored center points to congenital thicker than the holes that they surround. They correlate
nevus or accessory nipple; a dark brown or black center with rete ridges that are widened by pigment-laden malig-
points to a Clark or Reed nevus; a blue center is consis- nant melanocytes.
tent with a combined congenital nevus; and a white center Peripheral black dots and clods correlate with pig-
makes the diagnosis of DF most likely—subject to the other mented pagetoid melanocytes and nests of melanocytes
clues to DF mentioned above. Finally, a symmetrical com- close to the stratum corneum where melanin is expected
bination of central reticular lines with either radial lines or to appear black.
pseudopods (or both) peripherally is consistent with the White lines must be whiter than normal surrounding
diagnosis of Reed nevus. After puberty such lesions should skin and may be polarizing-specific, or alternatively, white
be excised as melanoma can sometimes present in this way. lines that are seen in both modalities. Polarizing-specific
Any asymmetrical combination of reticular lines with white lines are shiny white lines orientated perpendic-
another pattern must be assessed very carefully for clues ularly to each other but not crossing. They are only seen
to melanoma, and if none are present then the differential with polarizing dermatoscopy but they may correlate with
diagnosis includes both Clark and congenital nevi. reticular white lines seen with nonpolarized dermato
scopy. Polarizing-specific white line can also be seen com-
monly in BCC as well as DF and Spitz nevus. They are not
CLUES TO MELANOMA2,7,8
specific to these lesions but their presence is not expected
With respect to color these clues depend on the fact that in any other type of nevus or in seborrheic keratoses. If
melanin appears as different colors depending on its they are seen in such lesions, they should be excised to
depth in the skin.9 Melanin, being a very efficient pigment, rule out malignancy even if there is a history of preceding
Fig. 12.9: Clues to melanoma—asymmetry plus: “gray dots” (upper

left); “thick lines reticular” and “eccentric structureless area light
brown” (upper center); “eccentric structureless blue” and “black clods
peripheral” (upper right); “lines radial and pseudopods, segmental”
(lower left); “polarizing-specific white lines” (lower right with non
polarized dermatoscopy—lower center).
trauma. Polarizing-specific “white” lines appear blue in

some lesions and these polarizing-specific lines, with the
same perpendicular morphology and only seen in polari
zing-specific mode, have the same diagnostic significance.
Lines radial or pseudopods segmental correlate with
fascicles of pigmented melanocytes extending from the
periphery of a lesion and they signify radial growth. In
melanomas, they should be distributed asymmetrically Fig. 12.10: Clues to melanoma—asymmetry plus: polymorphous
and should extend from reticular lines, clods, or structure- vessels and polarizing-specific white lines (upper), polygons (both
lesions lower).
less areas of equivalent pigmentation to the radial lines
or pseudopods. This can distinguish them from the radial
lines seen in BCCs.
Polymorphous vessels in melanomas are expected to THE PATTERN OF LINES PARALLEL
include various types of linear vessels in raised portions A lesion with one pattern, lines parallel, or a lesion with
and patterns of dot vessel as well as any pattern of linear more than one pattern but with a primary pattern of lines
vessel in macular portions. Generally, other clues apart parallel and that is pigmented by melanin, will be restricted
from polymorphous vessels (pigment clues and/or white to the melanocytic or benign keratinocytic category.
lines) are expected in a melanoma and the vessel clues are A pattern of lines parallel only, on acral skin, in which
then useful in differentiating melanoma from pigmented the lines, pigmented by melanin, are located on the der-
basal cell carcinoma (pBCC) and pSCC in situ. matoglyphic ridges, is a clue to melanoma but can also
Polygons10 are defined as geometric polygonal shapes, rarely be seen with any type of acral nevus. Clues to nevus
complete or incomplete, bounded by straight lines, or by include onset in youth combined with long-term stability
a straight pigment interface, meeting at angles and larger but the index of suspicion should be high and evidence
than the holes caused by individual follicles and larger by of the onset at mature age and/or change should lead to
far than the holes bounded by reticular lines (Figs. 12.9 an appropriate biopsy. Of course, very large size or varia-
and 12.10).11,12 tions in pigment density in poorly defined lesions may be
additional clues to melanoma. It should be remembered

that melanomas in these locations may be very lightly pig-
mented but with small areas of subtle ridge-pattern pig-
mentation.
A pattern of lines parallel only, on acral skin, pigmented
by blood products, is due to intracorneal hemorrhage and
additional clues include satellite clods. Exogenous pigment
like that caused by silver nitrate therapy to warts can also
cause a ridge pattern.
A pattern of lines parallel only, on acral skin, in the
dermatoglyphic furrows and pigmented by melanin, is
consistent with the diagnosis of nevus.
A crossing pattern as pattern of lines parallel only,
on acral skin, with lines crossing both ridges and furrows
should be resolved into a parallel furrow or ridge pattern
by tilting the dermatoscope, to facilitate assessment as
described above.
A primary pattern of lines parallel, combined with any
other pattern, should be examined very carefully for clues
Fig. 12.11: Clues to melanoma on acral skin and the nail matrix. The
to melanoma. Clues to melanoma include those described upper images are patterns of parallel lines on the dermatoglyphic
above for the assessment of reticular-pattern lesions with ridges on acral skin. Although the lesion on the upper left was a corneal
the addition of the clue of a pattern of parallel lines in the hemorrhage, there were no satellite clods as a clue to that. The lesion
had almost cleared after 2 weeks. The lesion on the upper right was a
dermatoglyphic ridges seen in any part of the lesion. small acral melanoma. The broad ridge pattern is best appreciated at
A primary pattern of lines parallel, in the furrows, may the edges of the lesion, which is symmetrical. The lower lesion displays
be consistent with a diagnosis of nevus if the lesion is sym- lines parallel varying in width, interval, and color (lines parallel chaotic)
in the nail plate of a thumb and nail-matrix biopsy conformed the
metrical and there are no clues to melanoma, but if the
diagnosis on melanoma in situ.
lesion is asymmetrical and there are any of the described
clues to melanoma, then the possibility of melanoma
arising in association with a nevus must be considered In melanoma, the radial lines will be connected to
(Fig. 12.11). either lines reticular or to a pigmented structureless area,
or pigmented clods, as heavily pigmented as the radial
THE PATTERN OF LINES RADIAL lines.
In BCC the radial lines will often converge together,
A lesion with one pattern, lines radial, or a lesion with
and this convergence may or may not be to a central clod,
more than one pattern but with a primary pattern of lines
a dot, or a line. Radial lines, converging to a central point
radial, which is not a DF, will be restricted to the melano-
within a lesion, rather than at the periphery are highly
cytic, BCC, and SCC categories.
specific for BCC. Also in BCC in contrast to melanoma, the
The pattern of radial lines always occurs in combination radial lines may project from a hypopigmented area.
with another pattern. In pigmented Bowen’s disease, radial lines peripheral
If the lesion is symmetrical, the radial lines must be segmental are usually comprised of dots in linear arrange-
peripheral and circumferential. If in such a lesion the cen- ment.
ter is structureless and white, the provisional diagnosis is
DF. If the center is structureless and brown, black, or gray,
then Reed nevus is the likely diagnosis. If the center has a
THE PATTERN OF LINES CURVED
pattern of dark clods, then Reed nevus is also likely. A lesion with one pattern, lines curved, or a lesion with
If the lesion is asymmetrical, then the radial lines must more than one pattern but with a primary pattern of lines
be segmental and this is a clue to malignancy, either mela- curved will be restricted to the melanocytic and benign
noma, pBCC, or pSCC in situ. keratinocytic categories.
Fig. 12.13: Each of these three lesions has a pattern of lines peripherally
combined in the lesions in the left and right with a central structureless
Fig. 12.12: The lesion on the left has one pattern lines reticular and area and in the lesion in the middle with a central pattern of clods.
one color brown. The gradual (nonabrupt) border points to a diagnosis The lesion on the left is symmetrical and has the clue of white dots to
of Clark nevus. The lesion on the right has one pattern lines curved support a diagnosis of congenital nevus. The lesion in the middle is
and with an abrupt border this is most consistent with the diagnosis also symmetrical, and the pattern of peripheral lines combined with
of solar lentigo. central clods is also consistent with congenital nevus. The fact that
the lines at one end are branched and at the other end curved (or as
the clinician thought radial) leads to excision but in retrospect this
variation was not consistent with the chaotic behavior of malignant
A lesion with one pattern, lines curved can be either tissue. The lesion on the right is asymmetrical, the central pink
a solar lentigo or a seborrheic keratosis, and these can structureless area extending to the periphery on one side but not the
be distinguished according to specific clues as described other. In addition to the clue of an eccentric structureless area (not skin
colored), there is the clue of lines radial segmental at the upper border
above.
of the dermoscopic image. The asymmetry of this lesion, although it
A primary pattern of lines curved, combined with has a central structureless area and a peripheral pattern of lines like
a secondary pattern, can be combined with any of the the other two lesions, is due to a degree of disorganization, which is
other patterns, and if it has only one color brown, it is quite consistent with the chaotic behavior of malignant tissue. It was
an invasive melanoma.
also likely to be a solar lentigo or a seborrheic keratosis
whether symmetrical or not. If any other colors of mela-
nin are present, a careful search for clues to melanoma is
necessary before making a diagnosis of either seborrheic THE PATTERN OF CIRCLES
keratosis or lichen planus like keratosis (LPLK) (Figs. 12.12 A lesion with one pattern, circles, or a lesion with more
and 12.13). than one pattern but with a primary pattern of circles, in
which the circles are one of the colors of melanin and that
THE PATTERN OF PSEUDOPODS is not a DF, will be restricted to the melanocytic, benign
keratinocytic, and SCC categories.
A lesion with a pattern of pseudopods will always have this A pattern of circles pigmented by melanin can be
pattern in combination with another pattern and its diag- caused by either pigment in follicular epithelium or, alter-
nosis is restricted to the melanocytic category only. This is natively, by basal hyperpigmentation in the presence of
the most specific of all patterns. acanthosis that causes the individual units of the rete-
A pattern of pseudopods, which can only occur ridge reticular pattern to be separated from each other and
peripherally, will occur in combination with a central appear as circles.
pattern, which may be structureless, less often clods, and A pattern of pigmented circles only, which define folli-
rarely lines reticular. In all cases, the differential diagnosis cles on the head or neck, is a significant clue to melanoma
includes melanoma and Reed or, rarely, Spitz nevus. regardless of color,13 the differential diagnosis being solar
The dermoscopic description should be independent lentigo if they are brown and pSCC in situ and LPLK if they
of factors such as age but such factors are relevant to treat- are gray. Biopsy may be necessary to resolve the diagnosis.
ment decisions. After puberty all such lesions, whether Unlike a pattern of pigmented circles on facial skin, the
symmetrical or not, should be excised (Fig. 12.14). pattern of structureless pigment on facial skin interrupted
Fig. 12.15: Both of these pigmented lesions are located on facial skin
so as predicted, the pigment is interrupted by follicular openings. On
the left, a pattern of gray circles is a compelling clue to melanoma while
on the right a pattern of curved lines interrupted by follicular openings
Fig. 12.14: This lesion on the forearm of a 9-year-old child has a
is simply assessed as one pattern lines curved, one color brown with
peripheral circumferential pattern of lines radial and pseudopods
a sharply demarcated scalloped border as an additional clue to solar
combined symmetrically with a pattern of clods of equally dark
lentigo. Follicular opening does not rate as either a pattern or a clue
pigmentation. When radial lines and pseudopods are combined in a
and, unless defined by a circular line, they should be ignored.
concentric pattern, they are regarded as one pattern, defaulting to
the more specific structure of pseudopods. The differential diagnosis
includes Reed nevus and melanoma. Histology confirmed this as a
Reed nevus, which was the expected diagnosis in a child. A pattern of white circles (whiter than the surrounding
skin), combined symmetrically or asymmetrically with a
pattern of gray dots on the head or neck, is a clue to pAK
by follicular openings has no diagnostic significance at all or pSCC in situ. These dots may be randomly distributed
apart from being a clue that the lesion is on facial skin. between the white circles or they may surround them
Although pigmented circles defining follicles are occa- as gray circles, concentrically located around the white
sionally seen in melanomas on the trunk and extremities, circles (Figs. 12.15 and 12.16).
they are not regarded as a clue to melanoma at these loca-
tions as they commonly occur in benign lesions.
A pattern of pigmented circles only that do not surround THE PATTERN OF CLODS
follicles should be regarded in the same way as reticular lines A lesion with one pattern clods or a lesion with more than
and as they caused by acanthosis they are a compelling clue one pattern but with a primary pattern of clods and which
to seborrheic keratosis. is not a DF will be restricted to the melanocytic, benign
A primary pattern of pigmented circles can be com- keratinocytic, and BCC categories.
bined symmetrically as a peripheral pattern with a central In the case of one pattern clods, the differential diagno-
structureless or polarizing-specific white-line pattern in a sis is sorted according to the color of the clods as detailed
DF. For practical purposes there are no other symmetri- in Figure 12.5.
cal combinations of a pattern of circles with clod, dot, or The differential diagnosis, if there is a single color,
structureless patterns. includes BCC if the color is orange (caused by ulceration
For asymmetrical patterns that include a primary pat- and serum) or blue; congenital nevus, if they are skin col-
tern of pigmented circles defining follicles, on the head or ored or brown; seborrheic keratosis, if they are skin col-
neck, the diagnosis of melanoma must be very strongly ored, yellow, orange, or white; hemangioma if they are
suspected.13 Such a pattern on the body should be assessed red, purple, or black; and blood, if they are red or black.
according to previously defined clues to melanoma, which If there is more than one color with melanin pigment
means the pigmented circles would be regarded as a clue dominant and the colors being symmetrically combined,
to melanoma only if they were gray. the differential diagnosis includes congenital and Spitz
Asymmetrical patterns with a primary pattern of nevi. If the colors are combined asymmetrically, then mel-
pigmented circles that do not define follicles should be anoma and BCC must be distinguished by specific clues.
assessed as if the circles were reticular lines. Clues to melanoma have been described. Specific clues
to BCC are described at the end of this section on the

pattern of clods.
If there is more than one color, with nonmelanin
pigment dominant, the lesion may be an ulcerated BCC
(orange prominent), a seborrheic keratosis (yellow, white,
or orange prominent), or a hemangioma/vascular malfor-
mation (red or purple prominent) (Figs. 12.17 and 12.18).
A primary pattern of clods, combined with a second-
ary pattern (dots or structureless), can be symmetrical or
asymmetrical and the differential diagnoses are shown in
Figure 12.6.
Fig. 12.16: Both of these lesions on the torso contain pigmented For practical purposes the only symmetrical patterns
circles. The lesion on the left consists of one pattern circles (they with a primary pattern of clods will have brown clods
are not clods because the center is lightly pigmented compared to peripherally located around a central structureless area. A
the periphery), one color brown (the degree of color variation is not
significant and certainly not consistent with the disorganized behavior
skin-colored central structureless area points to the diag-
expected of malignant tissue). The circles are not related to follicles nosis of congenital nevus or Spitz nevus; a dark brown or
and are caused by basal hyperpigmentation of acanthotic rete ridges. black central structureless area is consistent with the diag-
Such a lesion is predictably a seborrheic keratosis and the sharply
nosis of Clark nevus or Spitz nevus; and a blue structure-
demarcated border is an additional clue to that diagnosis. The lesion
on the right has a pattern of short curved lines interrupted by a few less center makes combined congenital nevus more likely
pigmented circles that are related to follicles. Although there is some than the differential diagnosis of Spitz nevus. Although
gray color and the lesion is not perfectly symmetrical the diagnosis of peripheral clods are expected in a growing nevus, such
seborrheic keratosis was made with confidence due to the very regular
pattern of the short curved lines. The lesion also had a palpably rough a pattern should raise suspicion at the mature age when
surface texture uniformly over its surface as an additional clue to nevi are not expected to either appear as new lesions or
seborrheic keratosis. grow (Fig. 12.19).11
Fig. 12.17: All these three lesions have one pattern clods. On the left, a pattern of skin-colored clods with centered vessels is consistent with
either a seborrheic keratosis or congenital nevus. In the center, a pattern of red and purple clods, with no linear vessels, is consistent with a
hemangioma. On the right, a pattern of blue clods points confidently to the diagnosis of basal cell carcinoma.
Fig. 12.18: The lesion on the left has a pattern of orange keratin clods only, this being compelling evidence for seborrheic keratosis. The lesion
on the right also has a pattern of clods only, including a symmetrical combination of both central keratin clods (both orange and gray) and
peripheral skin-colored clods. Terminal hair is a clue that this is in fact a congenital nevus. It had been present since childhood.
If a pattern of clods is combined asymmetrically with a with a pattern of dots combined with a structureless
secondary pattern of dots or structureless, the differential pattern can fall into any of the defined categories.
diagnosis is sorted according to whether melanin or non- A solo pattern of dots can only be sorted on the basis of
melanin pigments are present. If the pigment is not mela- color. A pattern of brown dots may be seen in a Clark nevus
nin, the differential includes seborrheic keratosis (white, or pSCC in situ. A pattern of gray dots may occur in an
yellow, or orange), BCC (orange), hemangioma (red and/ LPLK, pAK, pSCC in situ, or a melanoma, and on the face
or purple), and melanoma, primary or metastatic (red a melanoma may have only one pattern and one color—in
and/or purple). If the pigment is melanin and there is other words, it may be symmetrical. A further clue to pSCC
one color brown, the prediction will be nevus, congenital in situ is that the dots may be in a linear arrangement.
or Spitz. In the case that there is more than one color, the A pattern of dots combined with the only possible
differential diagnosis includes melanoma, BCC, and seb- secondary pattern, structureless, is also sorted according
orrheic keratosis, and these alternatives should be sorted to the color of the dots. If the dots are brown, then solar
according to specific clues, discussed in detail above for lentigo and congenital nevus are added to the differential
melanoma and seborrheic keratosis and in the following diagnoses of Clark nevus and pSCC in situ. If the dots are
section for BCC. gray, the options are the same as for a solo pattern of gray
dots with the addition of BCC. If there are blue dots, the
CLUES TO BCC likely diagnosis is BCC. The occurrence of black dots is a
clue to melanoma, if they are peripheral, with a differential
Clues to BCC include lack of reticular lines plus one or
diagnosis of Clark nevus (Fig. 12.21).13
more of ulceration, blue clods, radial lines (as described
in the above section for a primary pattern of lines radial),
and monomorphous serpentine or serpentine branched CLUES TO PIGMENTED SCC IN SITU
vessels. Polarizing-specific white lines can support the
In a study of 52 consecutive cases of pSCC in situ (pig-
diagnosis of both BCC and melanoma but they are more
mented Bowen’s disease), the lesions were typified by the
frequently encountered in BCC (Fig. 12.20).
absence of a pattern of reticular lines and by the presence
of a pattern of dots and/or structureless zones.14 A single
THE PATTERN OF DOTS pattern was present in 53.8% with 48.1% being only struc-
As dots are the least specific pattern apart from the structureless. Hypopigmented (pink, skin colored, or white)
tureless pattern, a lesion with one pattern, dots, or a lesion structureless areas were present in 67.3%. The presence of
Fig. 12.19: On the left, a symmetrical lesion with a central pattern of reticular lines and peripheral pattern of clods (or dots depending on
perception), on a 30-year-old man is predictably a growing Clark nevus. The middle lesion may appear similar but the central structureless area
has an asymmetrical distribution of colors and one of these colors, gray, is a clue to melanoma. In this case, on the chest of a 50-year-old man the
peripheral clods or dots are not a clue to a growing nevus but to a growing melanoma in situ. Similarly, the lesion on the right, on the chest of
a 60-year-old lady, with peripheral clods surrounding a structureless center is not a nevus but is in fact a nodular melanoma, 3 mm in diameter
and 1 mm thick.
Fig. 12.21: Both lesions on the left have on pattern dots and one color
gray. The upper lesion is located on the back and this pattern on the
Fig. 12.20: Clues to basal cell carcinoma (BCC) include the absence torso or limbs is consistent with lichen planus like keratosis, which this
of reticular lines and ulceration, polarizing-specific white lines, and was. The lower lesion is on the face; at this location any lesion with
linear serpentine vessels (upper left: a small cluster of gray dots in the dermoscopic gray will have melanoma in the differential diagnosis.
lower left of the lesion makes this BCC pigmented for the purpose This lesion was an in situ melanoma. The lesion on the right has a
of analysis); blue clods; and linear serpentine vessels in a branched pattern of dots (left side of the image) combined asymmetrically with
arrangement with branches projecting from progressively thinner a structureless pattern on the right side. Red dots (not on their own
branches (upper right); lines radial segmental converging that constituting a pattern in revised pattern analysis) merge into brown
originate from a hypopigmented structureless area (lower left) with dots. The linear arrangement of the dots was consistent with the
the addition of polarizing-specific white lines in the image lower right confirmed diagnosis of squamous cell carcinoma in situ.
of the same lesion taken with the dermatoscope in polarizing mode.
A structureless pattern with one color black is usu-

ally caused by an old hemorrhage into or onto the skin,
or thrombosis of a hemangioma, and structureless red is
most consistent with a fresh hemorrhage into the stratum
corneum. Very rarely a Clark nevus, a Reed nevus, or a
melanoma can be structureless and black. A structureless
blue lesion is consistent with a blue nevus unless there is a
history that raises the likelihood of melanoma metastases. A
structureless brown lesion can be an ephelis, solar lentigo, or
pSCC in situ.
A structureless pattern with more than one color is
sorted according to whether the dominant pigment is mel-
anin or not. If white, yellow, or orange pigment is domi-
nant, the possibilities include seborrheic keratosis, BCC,
and amelanotic melanoma. If red color dominates then
Fig. 12.22: Four cases of pigmented squamous cell carcinoma (SCC)
in situ: a pattern of brown dots in linear arrangement combined the likely diagnosis is a fresh hemorrhage in the stratum
asymmetrically with a structureless area in the lower left of the lesion corneum. If melanin pigment is dominant and the colors
(upper left); a pattern of brown dots in linear arrangement combined are combined symmetrically, then a diagnosis of nevus is
asymmetrically with a structureless area in the lower half of the lesion
expected (congenital, congenital combined, blue, Clark,
(upper right); a pattern of lines radial segmental composed of dots
in linear arrangement combined asymmetrically with a structureless Spitz, or Reed). If melanin pigment is dominant and the
area, partly hyperpigmented and partly hypopigmented (lower left); a colors are combined asymmetrically, then the differential
structureless pigmented lesion on the face with the clue of lines radial diagnosis includes melanoma, primary, or metastatic and
segmental on the upper right of the lesion and the additional clues to
SCC in situ on the face, of white circles, whiter than surrounding skin
pSCC in situ (Fig. 12.24).15
(lower right).
CHAOS AND CLUES: A DECISION
ALGORITHM FOR PIGMENTED LESIONS
brown or gray dots in a linear arrangement was present in
21.2% and the presence of a linear arrangement of coiled BASED ON REVISED PATTERN ANALYSIS
vessels was present in 11.5% (Fig. 12.22). Revised pattern analysis is designed to lead to a provi-
sional diagnosis in a logical stepwise process. Chaos and
THE STRUCTURELESS PATTERN clues is an algorithmic method that uses pattern analysis
to guide the clinician in a stepwise process to the decision
A structureless pattern is the least specific of all, and as about whether a biopsy is indicated.8
with a pattern of dots; any lesion with a structureless-only The flowchart for the chaos and clues algorithm is
pattern can fall into any of the defined categories. The shown in Figure 12.25.
possibilities are numerous and they can only be sorted by
colors and the arrangement of these colors, plus the clues Chaos
seen due to pigmented structures, which, although not Chaos is defined as the presence of dermoscopic asym-
sufficient to form a pattern, may provide valuable clues. metry of pattern and/or color and it is assessed by the
In lightly pigmented structureless lesions, vessels may be method described for RPA. Although natural laws (gravity,
seen and, although they do not contribute to any pattern electrical and magnetic fields, surface tension, and feed-
of pigmented structures, these vessels may provide clues back mechanisms) favor symmetry, malignant tissue
to the diagnosis. For example, a structureless lesion may defies natural laws and this is the basis for both dermato-
display a polymorphic pattern of vessels including a dot pathological and dermoscopic chaos in malignant tissue.8
pattern as a clue to the diagnosis of melanoma. Small frag- Another feature that is an additional property of many
ments of reticular lines, if also present, could add addi- malignant chaotic lesions is chaos of border abruptness
tional weight to this evidence. [chaos of border abruptness was first recognized and
The differential diagnoses of structureless lesions accor described by Francis Drugge, the 12-year-old son of a der-
ding to color are shown in Figure 12.23. matologist, Rhett Drugge (Stanford, CT, USA)]. Although
Fig. 12.23: The stepwise analysis of clues for pigmented lesions with one pattern structureless.
to an ink-spot lentigo or solar lentigo (see Fig. 12.12, right).

Chaos of border abruptness is seen when parts of the bor-
der are abrupt and parts gradual (see all of the melanomas
in Figure 12.9, top row) (Fig. 12.26).
Clues
1. Gray or blue structures (including structureless): This
clue, in a chaotic lesion, applies to both melanocytic
and nonmelanocytic malignancies. Gray color is the
most sensitive clue to malignancy and is seen in most
in situ melanomas and many pBCC and pSCC; see Fig-
ure 12.2; Figure 12.9, upper left and upper right; Figure
12.10 lower images, Figure 12.11 lower image, Figure
12.15 left image, Figure 12.17 right image, Figure 12.19
Fig. 12.24: This lightly pigmented lesion has one pattern structureless, middle and right images, Figure 12.20, Figure 12.21
the small area of gray dots constituting a clue to malignancy although right side, and Figure 12.24. Blue color correlates with
being insufficient for a pattern. In addition to the clues of asymmetry pigment in the deep dermis, most commonly in melano-
of color (brown, gray, pink, and white), this lesion has polymorphous
cytes or nests of BCC.
vessels including patterns of both linear (serpentine) and dot vessels,
pointing correctly to the diagnosis of melanoma. Note the feature 2. An eccentric structureless area must cover a sufficient
of peripheral structureless brown, this being reported as a clue to portion of the lesion to form a pattern; it must be
hypopigmented melanoma. It should be noted that a significant contrasted to a structured pattern that is also within the
proportion of melanomas, like this one, do not have any reticular lines.
lesion and it must be a color other than skin colored.
If colored with the colors of melanin, it is produced
border abruptness is assessed in the ABCD method of der- by the chaotic behavior of malignant melanocytes; if
matoscopy, this is given most significance in that method pink, it is caused by increased blood flow; and if white,
when the total border is abrupt. The ABCD method would it may correlate with fibrosis after regression. This clue
therefore allocate the highest score for border abruptness also applies to both melanocytic and nonmelanocytic
Fig. 12.25: The chaos and clues algorithm. Pigmented lesions are first assessed for the presence of chaos (defined as dermoscopic asymmetry of
pattern and/or color) and if chaos is present they are examined or any one or more of nine clues to malignancy. If a clue is present, an adequate
biopsy is considered unless an unequivocal diagnosis of seborrheic keratosis can be made by pattern analysis. There are four exceptions in which
biopsy is considered even for nonchaotic lesions: any changing lesion on an adult, a nodular or a small (<6 mm) lesion which has any clue to
malignancy, any lesion on the head or neck with either pigmented circles or dermoscopic gray color and any acral lesion with a parallel ridge
pattern.
malignancies; see Figure 12.2, Figure 12.9 upper row, Fig- correlate with fascicles of pigmented melanocytes
ure 12.13 right, Figure 12.21 right, Figure 12.22 upper extending from the periphery of a lesion and they sig-
row and bottom left. nify growth. In melanomas, they should be distrib-
3. Thick lines reticular are defined when the lines are uted asymmetrically and should extend from reticular
thicker than the holes that they surround and they lines, clods, or structureless areas of equivalent pig-
correlate with rete ridges, which are widened by pigmentation to the radial lines or pseudopods (see Fig.
ment-laden malignant melanocytes. This clue is specific 12.9 bottom left and Fig. 12.26 bottom right). This can
to melanoma as the presence of reticular lines rules distinguish them from the radial lines seen on BCCs,
out the diagnosis of BCC or SCC; see Figure 12.9 upper which may project from hypopigmented structureless
middle. areas (see Fig. 12.20 bottom row). Lines radial segmen-
4. Black dots and clods, peripheral, correlate with pig- tal are also seen in pSCC in situ and they are usually
mented pagetoid melanocytes and nests of melano-
created by dots in a linear arrangement (see Fig. 12.22
cytes in melanomas and therefore this clue should
upper right and lower row).
be specific to melanomas. In reality, because dots are
6. White lines must be whiter than normal surrounding
common in both pBCC and pSCC in situ, and because
skin and they may be polarizing-specific, or alterna-
gray may be perceived as black, this clue can also be
tively, white lines that are seen with both modalities.
seen in those lesions. The reason for the designation
Polarizing-specific white lines are shiny white lines
that they be peripherally located is because central
black dots can be seen centrally in nevi that have been orientated perpendicularly to each other but not
traumatized, correlating with pigment in ascending crossing. They are only seen with polarizing derma-
keratinocytes. Pagetoid spread can occur anywhere toscopy but they may correlate with reticular white
in a melanoma, so when black dots or clods are seen lines seen with nonpolarized dermatoscopy. Polariz-
peripherally they are regarded as a clue to malignancy. ing-specific white lines can be seen very commonly in
5. Lines radial or pseudopods segmental are clues to BCC (pigmented or nonpigmented) and they are not
malignancy, pseudopods being specific to melanoma unusual in melanoma (pigmented or nonpigmented).
and lines radial segmental being found in all three pig- They are only rarely seen in pSCC in situ. They are also
mented malignancies. In melanomas, these structures commonly seen in both DF and Spitz nevi but their
A B
C D
Figs. 12.26A to D: Assessment for the presence of chaos of four different lesions on the same patient: (A) a concentric nonchaotic pattern with
clods centrally surrounded by a structureless area that is surrounded by a pattern of lines; (B) a concentric nonchaotic pattern with skin-colored
clods centrally and reticular lines peripherally. The shape of the lesion is irrelevant; (C) a nonchaotic structureless pattern, hyperpigmented
centrally with relatively hypopigmented areas at the upper and lower extremities; (D) a chaotic lesion, in this case by all parameters—pattern,
color, and border abruptness. Lesions A to C have not been excised but they have the morphology of congenital nevi. Lesion D, being chaotic
and with the clue of pseudopods, was a melanoma in situ.
presence is not expected in any other type of nevus raised portions, and a pattern of dot vessel as well as
(unless traumatized) or in seborrheic keratoses. any pattern of linear vessel in macular portions. Gene
7. Polymorphous vessels are a clue to both melanomas rally, other clues apart from polymorphous vessels
and pBCC but not to pSCC in situ. Pigmented BCC (pigment clues and/or white lines) are expected in a
often has a monomorphous pattern of serpentine or melanoma and the vessel clues are then useful in dif-
serpentine branched vessels but it may have a pattern ferentiating melanoma from pBCC and pSCC in situ.
of polymorphous linear vessels, especially on the Pigmented SCC in situ is expected to have a mono-
lower limb. A pattern of dot vessels is not expected in morphous pattern of coiled vessels, which may resolve
pBCC but ulceration, commonly present in BCC, and as dots depending on visual acuity.
associated keratinization may produce polymorphous 8. Polygons are defined as geometric polygonal shapes,
vessels including looped vessels in radial arrangement complete or incomplete, bounded by straight lines, or
and even dot vessels. In melanomas, polymorphous by a straight pigment interface, meeting at angles and
vessels may include various types of linear vessels in larger than the holes caused by individual follicles and
larger by far than the holes bounded by reticular lines. in stone. It has been designed as a useful tool, avoiding
This clue, in a chaotic lesion, is not only a valuable clue tedious mathematical calculations, unburdened by a lan-
to melanoma but may also rarely be seen in pBCC. guage of innumerable poorly defined metaphorical terms
9. Lines parallel on the ridges (acral) or lines parallel chaotic carrying preconceived diagnostic implications, and suitable
on the nails are a clue to melanoma, specifically, on for seamless integration into routine practice. Individuals
acral skin or in nail matrix, respectively. This is the only are encouraged to use it as a framework on which they orga-
one of the listed clues to malignancy that is specific to nize their accumulated experience as they individualize the
a particular anatomical site. It is important to remem- method for their own style and practice.
ber that the longer an acral or nail-matrix melanoma
remains untreated; the more likely it is to develop any REFERENCES
of the other clues to melanoma. Melanoma may also
1. Kittler H. Dermatoscopy: Introduction of a new algo-
arise in an acral nevus in which case any of the other
rithmic method based on pattern analysis for diagno-
eight clues will override a benign parallel furrow pat- sis of pigmented skin lesions. Dermatol Pract Concept.
tern, which may be present; see Figure 12.11 upper 2007;13(1):3.
right and lower image. 2. Kittler H, Rosendahl C, Cameron A, et al. Dermatoscopy.
Austria: Facultas; 2011.
3. Pehamberger H, Steiner A, Wolff K. In vivo epilumines-
EXCEPTIONS cence microscopy of pigmented skin lesions. I. Pattern
analysis of pigmented skin lesions. J Am Acad Dermatol.
Chaos and clues was tested on a consecutive series of pig- 1987;17(4):571-83.
mented lesions, the majority of melanomas in the series 4. Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of
being in situ, and was found to have a diagnostic sensitivity pigmented skin lesions: results of a consensus meeting via
of 90.6% (BCC: 98.5%, SCC: 86.5%, and melanoma: 79.3%) the Internet. J Am Acad Dermatol. 2003;48(5):679-93.
5. Marghoob AA, Braun R. Proposal for a revised 2-step algo-
with a specificity of 62.7% for the diagnosis of malignancy,
rithm for the classification of lesions of the skin using der-
of any type.7 In an attempt to move the sensitivity closer moscopy. Arch Dermatol. 2010;146(4):426-8.
to 100% the following exceptions are included, to select 6. Tschandl P, Rosendahl C, Kittler H. Accuracy of the first step
lesions for biopsy, even if not chaotic: of the dermoscopic 2-step algorithm for pigmented skin
1. Any changing lesion on an adult. This includes a lesion lesions. Dermatol Pract Concept. 2012;2(3):203a08.
7. Rosendahl C, Tschandl P, Cameron A, et al. Diagnostic accu-
with a history of change, lesions with monitored
racy of dermatoscopy for melanocytic and nonmelanocytic
change, and lesions with dermoscopic clues to change pigmented lesions. J Am Acad Dermatol. 2011;64(6):1068-73.
such as the presence of peripheral clods (see Fig. 12.19 8. Rosendahl C, Cameron A, McColl I, et al. Dermatoscopy in
middle and right). routine practice—“chaos and clues.” Aust Fam Physician.
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9. Weismann K, Lorentzen HF. Dermoscopic color perspec-
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method of dermatoscopy (see Fig. 12.19 right: this 3-mm non-acral lentiginous growth pattern melanomas. Derma-
diameter nodular melanoma was arguably symmetrical tol Pract Concept. 2014;4:77-82.
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and/or any dermoscopic gray. This clue acknowledges 12. Cohen YK, Elpern DJ, Wolpowitz D, et al. Glowing in the dark:
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ENTOMODERMOSCOPY 13
Entomology refers to the study of insects and their environment. Consequently,
entomodermoscopy would lead to the description of dermoscopic aspects of insect-related diseases.
Actually, the term involves not only the evaluation of insect reactions under dermoscopy
but also of infectious diseases (viral and fungal) and also parasitic infestations.
Clearly some of these skin conditions have a well- defined dermoscopic pattern,
and eventually the offending agent might also be visualized.
Entomodermoscopy 287
Dermoscopy has been used for improving accuracy in the Common warts are more keratotic and present more
diagnosis of pigmented and nonpigmented skin tumors. frequently with hemorrhagic structures. In contrast,
Additionally, it has been proven to help in the daily der- flat warts usually show the well-distributed dotted vessels
matological practice when evaluating a sort of different (Fig. 13.2).2 Vascular pattern of flat warts might be especially
clinical scenarios permitting the identification of infestation important to differentiate them from other micropapular
agents and of other infectious diseases. eruptions on the face like acneiform and comedonic lesions
Entomology refers to the study of insects and their or milia cysts. Plantar warts also present hemorrhagic dotted
environment. Consequently, entomodermoscopy would or linear vessels that allow us to rule out acral amelanotic
lead to the description of dermoscopic aspects of insect- melanoma or callus (Fig. 13.3).3 Genital warts also demon-
related diseases. Actually, the term involves not only the strate a similar vascular pattern. The occurrence of hyper-
evaluating of insect reactions under dermoscopy but also keratotic papules with dotted vessels on the genital area is
of infectious diseases (viral and fungal) and also parasitic highly suspicious of HPV infection and helps the clinician
infestations.1,2 to differentiate them from pearly penile papules.1
Clearly some of these skin conditions have a well- Finally, dermoscopy is extremely important to moni-
defined dermoscopic pattern, and eventually the offend- tor warts’ treatment. Some series of patients demonstrated
ing agent might also be visualized. The major descriptions that naked eye evaluation was less accurate to define per-
of entomodermatoscopy will be mentioned below. sistent warts after cryotherapy than dermoscopy; therefore,
it should be used to optimize therapies.5
VIRAL INFECTIONS
Warts Molluscum Contagiosum
Viral warts are benign skin lesions caused by human papil Molluscum contagiosum is a cutaneous infection caused
lomavirus (HPV). Diagnosis is usually made in a clinical by a poxvirus. It is more common among children, espe-
basis but dermoscopy might be helpful to reveal equivocal cially with atopy and immunosuppressed individuals. It
lesions. On dermoscopy they present as hyperkeratotic can be clinically diagnosed presenting as normochromic
papules with homogeneously distributed dotted vessels to erythematous papules with umbilicated center. Some
some presenting with hemorrhages (Figs. 13.1A and B). cases might be challenging and dermoscopy can also lead
Histopathological dotted vessels correspond to dilated to a correct evaluation.6
capillaries on papillary dermis and some might be throm- Dermoscopic aspects of molluscum contagiosum are
bosed leading to the hemorrhages.2-4 composed of whitish or yellowish polylobulated amorphous
A B
Figs. 13.1A and B: (A) Multiple thrombosed vessels in viral wart (Fotofinder Systems, Germany, 20× original magnification). (B) Multiple
thrombosed vessels in viral wart (Fotofinder Systems, Germany, 40× original magnification).
Fig. 13.2: Small well-distributed dotted vessels in flat warts (Fotofinder Fig. 13.3: Multiple thrombosed dotted and linear vessels in plantar
Systems, Germany, 20× original magnification). wart (Fotofinder Systems, Germany, 40× original magnification).
Fig. 13.4: Amorphous structures centrally distributed with peripheral Fig. 13.5: Multiple dark linear structures in tinea nigra (Fotofinder
telangiectatic vessels in molluscum contagiosum (Fotofinder Systems, Systems, Germany, 20× original magnification).
Germany, 20× original magnification).
structures centrally distributed surrounded by telangiec- melanoma and dermoscopy easily leads to the recognition
tatic vessels that do not cross the center of the lesion (Fig. of tinea nigra. It is characterized by the presence of light-
13.4).6 brown linear structures crossing and tangled (Fig. 13.5).1
Tinea Capitis
FUNGAL INFECTIONS
Tinea capitis is caused by different species of dermato-
Tinea Nigra phytes. It is more common among children and present
Tinea nigra is caused by the dematiaceous fungus Phaeo clinically as a patch of alopecia with tonsured hair. Ery-
annellomyces werneckii, also called Exophiala werneckii, thema and scales are frequent as well as have itchy sen-
Exophiala phaeoannellomyces or Cladosporium werneckii. sation. Definitive diagnosis is performed by culture but
It usually occurs on the plantar and palmar aspects of dermoscopy might be of great value for the initial sus-
children and young adults.2 It might mimic malignant piciousness. Comma-like hair is frequently seen in tinea
Fig. 13.6: Longitudinal striae of different colors in onychomycosis Fig. 13.7: Spiked pattern in onychomycosis (Fotofinder Systems,
(Fotofinder Systems, Germany, 20× original magnification). Germany, 20× original magnification).
capitis as well as tonsured hair.7 Darker-skin-type individuals

might also present with corkscrew-like hair.
Onychomycosis
Fungal infection of the nail plate is very common being
responsible for 50% of the nail disorders. Clinical inspec-
tion and cultural examination are usually sufficient to
diagnose the offending agent. Some cases might also be
challenging, especially in pigmented onychomycosis.
Some dermoscopic patterns have been reported in ony-
chomycosis patients like the spiked pattern, the longitu-
dinal striae pattern, and the linear edge pattern (Figs. 13.6
and 13.7).8
Fig. 13.8: “Jet with contrail” structure in scabies (Fotofinder Systems,
PARASITIC INFESTATIONS Germany, 20× original magnification).
Scabies
Scabies is caused by Sarcoptes scabiei variant hominis. It 93% of the cases to show a small brown triangular structure
is common and might also occur in an epidemic pattern. localized on the final portion of a linear scaly structure that
Clinical manifestations may vary substantially but it usually was called “jet with contrail” (Fig. 13.8). These structures
occurs as erythematous excoriated papules on the axillae, correspond, respectively, to the anterior aspect of the mite
wrists, interdigital spaces, and genital area. and to the scabiotic furrow.10 Higher magnification der-
Although skin scrapping and observation of epithelial matoscopes (50–70) facilitate the mite observation.
material under an optic microscope is the gold standard One clinical trial compared dermoscopy to skin scrap-
method for the identification of the mite, dermoscopy ping for the diagnosis of scabies. They found, respectively,
might play a major role in the evaluation of suspicious sensitivities of 91% and 90% and accuracies of 89% and
cases. Dermoscopy is less invasive, faster, and more prac- 95% for the methods. Interestingly, patients preferred to
tical to evaluate every necessary lesion and shows good have dermoscopy performed as it is a painless noninvasive
accuracy for scabies diagnosis.9 tool. Moreover, time to evaluate the patients was signifi-
Dermoscopic aspects of scabies were initially des cantly less also for dermoscopy corroborating that it is a
cribed by Argenziano et al. In their report, they found fast method for this purpose.9
Fig. 13.9: Dark-brown opening, violaceous structure and whitish chains Fig. 13.10: Dermatobia hominis maggot in a furuncular myiasis
in tungiasis (Fotofinder Systems, Germany, 20× original magnification). (Fotofinder Systems, Germany, 20× original magnification).
Tungiasis the visualization of the maggot might take longer. In order

Tungiasis is caused after skin infestation by the flea Tunga to avoid contamination of the dermatoscope, it is recom-
penetrans. It affects most commonly the lower extremities, mended to use a protective plaster on the lens when touch-
like the plantar region, the periungual tissue or the toes. It ing ulcerated skin. The maggot appears with a whitish to
is usually self-limited but in some cases, if not recognized yellowish color with small black spines. The maggot is
early, the infestation might lead to pain and secondary removed easily after death. It is recommended to occlude
infection. the opening for 24 hours. On the next day, one should
The dermoscopic is very characteristic.11,12 It is possible check again for breathing movements with dermoscopy. If
to observe a central pigmented ring, which corresponds they do not occur, it can be safely removed only by holding
to the chitin portion that covers the posterior aspect of the maggot with tweezers and gently pulling out.1,13
the flea exoesqueletum. Violaceous globules and whitish Lice
chains of globules are also seen (Fig. 13.9).11 The latter
Head lice are most frequent among children and are
structure corresponds to the eggs of the flea that will be
caused by infestation by Pediculus humanis capitis. Direct
expelled and can sometimes be visualized on the skin.11,12
transmission is very common, and prompt recognition
Furuncular Myiasis and treatment are recommended. It is usually character-
ized by pruritus and by the visualization of the louse on the
Furuncular myiasis occurs after infestation of the skin scalp and nits attached to the hair shafts.
by Dermatobia hominis maggots. Clinically, it is charac- Polarized light dermoscopes allow in vivo observa-
terized by a painful inflammatory nodule with a central tion of the louse and the nits. It is also possible to monitor
opening that does not relieve after topical or systemic anti- treatment efficacy as empty or filled nits might be seen.1
biotics. A single lesion is usually observed but infestations Nonpolarized contact dermoscopy might also be used for
by multiple maggots and consequently a variable number nits observation after cutting some of the affected hair and
of lesions might be seen. Therefore, its diagnosis might not attaching them with to the lens with a tape.14
be initially thought. Other lice like Phthirus pubis in the genital might also
Dermoscopy can be extremely important in these be better visualized by dermoscopy.
cases for early observation of the maggot. It is visualized
better with contact dermoscopy closing the nodule opening Larva Migrans
for some minutes. The maggot necessarily needs to breath Larva migrans is caused by the worm Ancylostoma bra-
and will appear at the surface of the opening (Fig. 13.10). ziliense. It is typically transmitted after barefoot walk on
If the opening is not occluded by the dermatoscope lens, contaminated soil with dogs and cats feces. Clinical history
Lupus Vulgaris
Lupus vulgaris is a variant of cutaneous tuberculosis and
may present with distinct clinical forms ranging from
isolated or multiple nodules to large plaques with “apple
jelly” aspect. On dermoscopy it is possible to observe
orange to golden structures and linear vessels as well as
whitish streaks.1
Leishmaniosis
Leishmaniosis is caused by protozoan of the genus Leish
mania. Clinical aspects are variable depending on the
agent and might be confounded with other skin condi-
tions. Dermoscopy of Leishmania infantum demonstrates
an erythema and other vascular structures in 100% of the
Fig. 13.11: Amorphous translucent light brown structures in a linear cases. Additionally, yellowish tears and a whitish star-
pattern in larva migrans (Fotofinder Systems, Germany, 20× original bust-like pattern that correspond, respectively, to follicular
magnification).
plugs and parakeratosis were also described.17
and physical examination are very characteristic and

REFERENCES
correspond to an itchy sensation on a linear erythema- 1. Tschandl P, Argenziano G, Bakos R, et al. Dermoscopy and
tous plaque on the feet or eventually buttocks (by seating entomology (entomodermoscopy). J Dtsch Dermatol Ges.
2009;7(7):589-96.
on the contaminated soil). The lesion tends to increase in
2. Zalaudek I, Giacomel J, Cabo H, et al. Entodermoscopy: a
length making a serpiginous pathway until the worm dies. new tool for diagnosing skin infections and infestations.
Amorphous translucent light brown structures in a linear Dermatology. 2008;216(1):14-23.
pattern were described in larva migrans although in the 3. Teoli M, Di Stefani A, Botti E, et al. Dermoscopy for treat-
majority of the cases clinical aspects might be sufficient to ment monitoring of viral warts. Dermatology. 2006;212:318.
the correct diagnosis (Fig. 13.11).1,15 4. Vazquez-Lopez F, Kreusch J, Marghoob AA. Dermoscopic
semiology: further insights into vascular features by screen-
ing a large spectrum of nontumoral skin lesions. Br J Der-
MISCELLANEOUS matol. 2004;150:226-31.
5. Bae JM, Kang H, Kim HO, et al. Differential diagnosis of
Irritative Dermatitis by Spider Spine plantar wart from corn, callus and healed wart with the aid
of dermoscopy. Br J Dermatol. 2009;160(1):220-2.
Tarantulas are large spiders that reach 30 cm in size and 6. Zaballos P, Ara M, Puig S, et al. Dermoscopy of molluscum
are not offensive for humans. Some individuals handle contagiosum: a useful tool for clinical diagnosis in adult-
those animals as a hobby. A case report of an irritative der- hood. J Eur Acad Dermatol Venereol. 2006;20(4):482-3.
matitis with erythematous papules on interdigital areas 7. Slowinska M, Rudnicka L, Schwartz RA, et al. Comma hairs:
and wrists mimicking scabies was reported. The visualiza- a dermoscopic marker for tinea capitis: a rapid diagnostic
method. J Am Acad Dermatol. 2008;59(5 Suppl):S77-9.
tion of the small black spicules instead of a potential sca-
8. Jesús-Silva MA, Fernández-Martínez R, Roldán-Marín R,
bies infestation reveals the correct origin of the reaction.16 et al. Dermoscopic patterns in patients with a clinical dia
g
nosis of onychomycosis-results of a prospective study
Ixodes ricinus including data of potassium hydroxide (KOH) and culture
Ixodes ricinus is potentially the vector for a series of infec- examination. Dermatol Pract Concept. 2015;5(2):39-44.
tious conditions as Lyme disease. If they are small (≤1 9. Dupuy A, Dehen L, Bourrat E, et al. Accuracy of standard
dermoscopy for diagnosing scabies. J Am Acad Dermatol.
mm), it might be confounded with a pigmented lesion,
2007;56(1):53-62.
even melanocytic nevi. Dermoscopy easily facilitates the 10. Argenziano G, Fabroccini G, Delfino M. Epiluminescence
differentiation and also permits us to observe remaining microscopy: a new approach to in vivo detection of Sarcop-
portions of the tick after mechanical removal.1 tes scabiei. Arch Dermatol. 1997;133(6):751-3.
11. Bakos RM, Bakos L. “Whitish chains”: a remarkable in vivo 14. Bakos RM, Bakos L. Dermoscopy for diagnosis of pediculo-
dermoscopic finding of tungiasis. Br J Dermatol. 2008; sis capitis. J Am Acad Dermatol. 2007;57(4):727-8.
159(4):991-2. 15. Lallas A, Zalaudek I, Argenziano G, et al. Dermoscopy in
general dermatology. Dermatol Clin. 2013;31(4):679-94.
12. Cabrera R, Daza F. Dermoscopy in the diagnosis of tungia-
16. Bakos RM, Rezende RL, Bakos L, et al. Spider spines
sis. Br J Dermatol. 2009;160(5):1136-7. detected by dermoscopy. Arch Dermatol. 2006;142:1517-8.
13. Bakos RM, Bakos L. Dermoscopic diagnosis of furuncular 17. Llambrich A, Zaballos P, Terrasa F, et al. Dermoscopy of cuta-
myiasis. Arch Dermatol. 2007;143(1):123-4. neous leishmaniasis. Br J Dermatol. 2009;160(4):756-61.
INFLAMMATOSCOPY 14
“It is always important to stress that clinical history and physical examination
findings remain highly necessary in this scenario.
Characteristic symptoms and signs added to a particular dermoscopic pattern or structures
then increase the level of suspiciousness of these groups of diseases. Nevertheless, histopathologic
examination should be performed in equivocal clinicodermatoscopic lesions.
Although the majority of the inflammatory cutaneous diseases might not show a pathognomonic
dermoscopic pattern, the observation of several structures or also the absence of others may help
in characterizing them. As they show few pigmented structures, the observation of vascular
patterns and colors are generally of great help.”
Inflammatoscopy 295
Dermoscopy is probably the most important noninva-

sive diagnostic tool for dermatologic practice, being con-
sidered the “dermatologist stethoscope.”1 Inflammatory
processes may occur secondarily in ordinary lesions and
change their usual clinical aspects. This phenomenon is
seen, for example, in some melanocytic nevi (Meyerson
nevus) or irritated seborrheic keratosis. Especially, the
current chapter will present dermoscopic patterns and
aspects of different major cutaneous inflammatory diseases
that have been reported.2,3
Dermoscopy may facilitate inflammatory dermatoses
recognition, differentiate them from skin tumors like basal
cell carcinoma, Bowen’s disease, and amelanotic mela-
noma and also help in monitoring therapeutic actions,
although it might sometimes give little information alone. Fig. 14.1: Homogeneous and symmetrically distributed dotted
It is always important to stress that clinical history and vessels in plaque psoriasis. (Fotofinder Systems, Germany, 20× original
physical examination findings remain highly necessary in magnification)
this scenario. Characteristic symptoms and signs added
to a particular dermoscopic pattern or structures then
increase the level of suspiciousness of these groups of may be found in several skin conditions, also in melano-
diseases. Nevertheless, histopathologic examination should cytic diseases. The clinicodermoscopic information of a
be performed in equivocal clinicodermatoscopic lesions. homogeneous and symmetric vascular pattern occurring
Although the majority of the inflammatory cutaneous in an erythematosquamous reaction suggests the diagnosis
diseases might not show a pathognomonic dermoscopic of psoriasis.
pattern, the observation of several structures or also the
absence of others may help in characterizing them. As PITYRIASIS ROSEA
they show few pigmented structures, the observation of
vascular patterns and colors are generally of great help.2,3 Pityriasis might clinically resemble guttate psoriasis. It is
Distinct dermoscopic aspects of cutaneous inflamma- characterized by the absence of the homogeneous dotted
tory diseases are described below. vessels and the presence of a collarette-like peripherally
distributed white scale and yellow background (Fig. 14.2).6
Dotted vessels may also be present in the plaques, but dis-
PSORIASIS tributed irregularly.2
Psoriasis is usually diagnosed on the clinical basis. Histo-
logically, it is characterized by hyperkeratosis, acanthosis, LICHEN PLANUS
and parakeratosis; elongated rete ridges; and capillary
loop dilatation. It is possible to recognize a characteristic Dermoscopy is especially helpful for the clinical diagnosis
dermoscopic pattern in psoriasis. It corresponds to the of lichen planus. It is possible to visualize in the majority
presence of multiple dotted vessels homogeneously and of the cases White streaks (92% of the cases), which corre-
symmetrically distributed over the lesion (Fig. 14.1).4,5 spond to the Wickham streaks, that can be observed fre-
These vascular structures correspond to the dilated pap- quently with the naked eye. Small linear vessels as well as
illary vessels associated with the epidermic changes. It is some dotted vessels are also seen in 80% of the cases
the dermoscopic representation of the Auspitz sign. Scales (Fig. 14.3).4,5 Darker skin type patients present hyperpig-
are also seen in dermoscopy and their quantity may be mented plaques that show dark-brown structures sur-
used as a parameter for treatment.2 Other variants, not in rounding the white streaks which may be confounded
psoriasis vulgaris, may present this pattern. Dotted vessels with dermatofibromas.7
Fig. 14.2: Collarette scale in pityriasis rosea. (Fotofinder Systems, Fig. 14.3: Whitish striae in lichen planus. (Fotofinder Systems, Germany,
Germany, 20× original magnification) 20× original magnification)
ECZEMAS vessels, pigmented structures, and whitish structureless

areas)(Fig. 14.6).2,10,11 Lupus scalp lesions are described
Eczemas do not have a characteristic dermoscopic aspect. elsewhere.12,13
Acute forms may show a generalized erythema with vesic-
ulation observed with the dermatoscope. Some vascular LICHEN SCLEROSUS AND MORPHEA
structures such as linear vessels may also be seen.2 Chronic
plaques might resemble psoriasis but dotted vessels are Both lichen sclerosus and morphea appear dermoscopically
irregularly distributed and yellow scales also might be pres- with white–yellow structures. Genital lichen sclerosus lesions
ent.8 It can help at least to rule out other conditions that might usually have linear vessels while extragenital lesions show
occur in this clinical scenario. keratotic plugs. Scattered black dots that correspond to
melanophages might also be seen (Fig. 14.7). Morphea
also show linear vessels and a lilac ring and keratotic plugs
URTICARIA
are not observed.2,8 Capillaroscopy with a dermoscope
Clinically, urticaria is characterized by erythemato-edema might also be helpful in evaluating some inflammatory
tous lesions. On dermoscopy, it is possible to observe diseases.14
erythema and dilated vessels that disappear with contact
dermoscopy (Fig. 14.4). It is particularly interesting to NONINFECTIOUS GRANULOMAS
differentiate them from urticarial vasculitis that generally
Immunologic granulomas have also been investigated with
shows small hemorrhagic structures (Fig. 14.7).9
dermoscopy. Generally, it is possible to observe a yellow
to orange background, sometimes whitish. In necrobiosis
DISCHOID LUPUS
lipoidica, there is a rich vascular network with arborizing
Dischoid lupus occurs most frequently in sun-exposed telangiectasias, mimicking basal cell carcinoma vascular
areas. It might be confounded with other dermatoses and structures that correspond to reticular dermis vessels and
dermoscopy can also help in its recognition. Moreover, small tortuous or linear vessels in the papillary dermis (Figs.
recent report demonstrated different structures that may 14.8A and B).15 Granuloma annulare presents with linear
occur in early-onset lesions (perifollicular whitish halo, vessels in the papular aspect of the lesion (Fig. 14.9).2 In sar-
follicular plugging, and white scales) (Fig. 14.5) and other coidosis, the lesions present in homogeneous or structure-
structures seen in long-standing lesions (telangiectatic less orange areas with linear vessels (Fig. 14.10).16-18
Inflammatoscopy 297
Fig. 14.4: Telangiectatic vessels in urticaria. (Fotofinder Systems, Germany, Fig. 14.5: Perifollicular whitish halo, follicular plugging and white
20× original magnification) scales in an early-onset dischoid lupus plaque. (Fotofinder Systems,
Germany, 20× original magnification)
Fig. 14.6: Telangiectatic vessels and whitish structureless areas in Fig. 14.7: Whitish area with keratotic plug and scattered black dots
long-standing dischoid lupus lesions. (Fotofinder Systems, Germany, in lichen sclerosus. (Fotofinder Systems, Germany, 20× original magni
20× original magnification) fication)
A B
Figs. 14.8A and B: Arborizing telangiectasias and yellow-orange background in necrobiosis lipoidica. (Fotofinder Systems, Germany, 20×
original magnification)
Fig. 14.9: Linear vessels in granuloma annulare. (Fotofinder Systems, Fig. 14.10: Orange background and linear vessels in sarcoidosis.
Germany, 20× original magnification). (Fotofinder Systems, Germany, 20× original magnification)
REFERENCES 9. Vázquez-López F, Fueyo A, Sánchez-Martin J, et al. Der-

moscopy for the screening of common urticaria and urti-
1. Tschandl P, Argenziano G, Bakos R, et al. Dermoscopy and caria vasculitis. Arch Dermatol. 2008;144:568
entomology (entomodermoscopy). J Dtsch Dermatol Ges. 10. Lopez-Tintos BO, Garcia-Hidalgo L, Orozco-Topete R. Der-
2009;7:589-96. moscopy in active discoid lupus. Arch Dermatol. 2009;145:358.
2. Vázquez-López F, Kreusch J, Marghoob AA. Dermoscopic 11. Lallas A, Apalla Z, Lefaki I, et al. Dermoscopy of discoid
semiology: further insights into vascular features by screen- lupus erythematosus. Br J Dermatol. 2012;168:284-8.
ing a large spectrum of nontumoral skin lesions. Br J Der- 12. Abraham LS, Piñeiro-Maceira J, Duque-Estrada B, et al.
matol. 2004;150:226-31. Pinpoint white dots in the scalp: dermoscopic and histo-
3. Zalaudek I, Argenziano G, Di Stefani A, et al. Dermoscopy pathologic correlation. J Am Acad Dermatol. 2010;63:721-2.
in General Dermatology. Dermatology. 2006;212:7-18. 13. Duque-Estrada B, Tamler C, Sodré CT, et al. Dermoscopy
patterns of cicatricial alopecia resulting from discoid lupus
4. Vázquez-López F, Manjón-Haces JA, Maldonado-Seral
erythematosus and lichen planopilaris. An Bras Dermatol.
C, et al. Dermoscopic features of plaque psoriasis and
2010;85:179-83.
lichen planus: new observations. Dermatology. 2003;207:
14. Hasegawa M. Dermoscopy findings of nail fold capillaries
151-6.
in connective tissue diseases. J Dermatol. 2011;38(1):66-70.
5. Zalaudek I, Argenziano G. Dermoscopy subpatterns 15. Bakos RM, Cartell A, Bakos L. Dermoscopy of early-onset
of inflammatory skin disorders. Arch Dermatol. 2006; necrobiosis lipoidica. J Am Acad Dermatol. 2012;66(4):e143-4.
142:808. 16. Pellicano R, Tiodorovic-Zivkovic D, Gourhant JY, et al.
6. Chuh AAT. Collarette scaling in pityriasis rosea demonstrated Dermoscopy of cutaneous sarcoidosis. Dermatology.
by digital epiluminescence dermatoscopy. Australas J Derma- 2010;221:51-4.
tol. 2001;42:288-90. 17. Brasiello M, Zalaudek I, Ferrara G, et al. Lupus vulgaris: a
7. Vázquez-López F, Maldonado-Seral C, López-Escobar M, new look at an old symptom—the lupoma observed with
et al. Dermoscopy of pigmented lichen planus lesions. Clin dermoscopy. Dermatology. 2009;218:172-4.
Exp Dermatol. 2003;28:554-64. 18. Lallas A, Zaballos P, Zalaudek I, et al. Dermoscopic patterns
8. Lallas A, Zalaudek I, Argenziano G, et al. Dermoscopy in of granuloma annulare and necrobiosis lipoidica. Clin Exp
general dermatology. Dermatol Clin. 2013;31(4):679-94. Dermatol. 2013;38:424-9.
TRICHOSCOPY 15
Lidia Rudnicka
“The term “trichoscopy” refers to dermoscopy or videodermoscopy of hair and scalp.
Trichoscopy is used for differential diagnosis of hair and scalp diseases,
monitoring treatment efficacy in individual patients and evaluation of therapeutic
or cosmetic products in clinical trials and animal experiments.
Any hand-held dermoscope or videodermoscope may be used to perform trichoscopy.”
Trichoscopy 301
The term “trichoscopy” was first used in literature in 20081

and it refers to dermoscopy or videodermoscopy of hair
and scalp.2 Trichoscopy is used for differential diagnosis of
hair and scalp diseases,3 monitoring treatment efficacy in
individual patients2 and evaluation of therapeutic or cos-
metic products in clinical trials and animal experiments.4
Any handheld dermoscope or videodermoscope may
be used to perform trichoscopy. Among handheld der-
moscopes, there are devices that require immersion fluid
and that use polarized light to cancel out reflections from
the stratum corneum. Polarized light dermoscopes may
have a contact or noncontact lens. Devices that combine
Fig. 15.1: Female androgenetic alopecia. Hair shaft heterogeneity,
contact and noncontact lenses (hybrid dermoscopes) also predominance of follicular units with only one hair shaft, yellow dots.
are available. The choice of a particular device to perform
trichoscopy is a matter of individual’s preference.
A normal terminal hair is uniform in thickness and color
alopecia follicular units with only one hair will usually pre-
throughout its length.5,6 Up to 10% of normal human scalp
dominate. Empty hair follicles present as yellow dots, usually
hairs are vellus hairs that appear short, thin, and hypopig-
sparsely distributed between the normal and thinned
mented on trichoscopy. Abnormalities in hair shaft struc-
hairs. The presence of yellow dots appears to be a variable
ture or color may be indicative of several hair and scalp
feature of androgenetic alopecia. In various studies, yellow
diseases. Hair follicle openings appear in trichoscopy as
dots were observed in 7–66% of women with androgenetic
small round structures, called “dots”. The following types
alopecia, depending on the study.2 Brown perifollicular
of dots may be distinguished: yellow dots (follicular open-
discoloration (the peripilar sign) is observed in 20–66% of
ings filled with sebum and keratotic material), black dots
patients (Fig. 15.1).
(follicular openings filled with pigmented hair residues),
white dots (follicular openings replaced by fibrotic tissue), Alopecia Areata
and pinpoint white dots (normal follicular openings that
The trichoscopy presentation of alopecia areata differs
appear lighter on dark background of sun-exposed skin
depending on disease activity. The hallmark features
or in patients with dark skin phototypes).7,8 The shape of
of active disease are exclamation mark hairs and black
scalp blood vessels, scaling, or exudates may also provide
dots.3,10 Other less frequent manifestations of active alopecia
some diagnostic information.2
areata are trichorrhexis nodosa (3–16%), monilethrix-like
hairs, and zigzag hairs. Zigzag hairs may also be present in
NONCICATRICIAL ALOPECIA tinea capitis, so this feature may be misleading, if not asso-
ciated with other trichoscopy features of alopecia areata.11
Androgenetic Alopecia Nonactive, long-lasting disease is usually characterized by
Androgenetic alopecia in men and women shares similar multiple, regularly distributed yellow dots.12 Some authors
trichoscopy features. The most typical, almost pathogno- indicate that yellow dots are not present in childhood alope-
monic, trichoscopy feature of androgenetic alopecia is the cia areata.13
simultaneous presence of thick, intermediate, thin vellus In the regrowth phase, multiple upright regrowing
hairs in one field of view of a dermoscope, also called hair hairs may be visible (Figs. 15.2A and B).
shaft thickness heterogeneity. This exemplifies the ongo-
ing process of hair follicle miniaturization.9 Vellus hairs Trichotillomania
may be present in a healthy person, but their proportion The most characteristic trichoscopy feature of trichotillo-
usually does not exceed 10%.5 A higher proportion of vellus mania is the chaotic arrangement of hairs broken at diff
hairs are indicative of androgenetic alopecia. Another typ- erent lengths. The distal ends of the broken hairs may be
ical trichoscopy feature is a decreased number of hairs per classified as transverse fractures, fractures with trichop-
follicular. A healthy follicular unit contains two or three tilosis (split ends), coiled hairs with a ragged ends, and
(sometimes four) hairs. In patients with androgenetic flame hairs.14 Black dots may develop when hair brake at
A B
Figs. 15.2A and B: Alopecia areata. (A) Multiple exclamation mark hairs and black dots are a marker of high disease activity. (B) Regularly
distributed yellow dots in a stable disease.
Fig. 15.3: Trichotillomania. Hairs broken at different lengths and black Fig. 15.4: Tinea capitis. Zigzag hairs (hairs bend at sharp angles) may
dots. also be observed in the initial phase of alopecia areata.
the scalp level.15-17 Yellow dots are generally not observed abnormalities are commonly accompanied by scaling,
in trichotillomania.15 Inui et al.18 and later Rudnicka et al.2 diffuse, or perifollicular.25 It was documented that the typ-
observed yellow dots in one patient with this condition. ical trichoscopy abnormalities are associated with both
These dots differ from yellow dots in other diseases by ectothrix and endothrix types of fungal invasion.26 Other
containing a black peppering in their central part.18 Excla- less common features of tinea capitis include block hairs,
mation mark hairs are rare in trichotillomania,19,20 but i-hairs, and zigzag hairs. Tinea capitis may present with
they may be a diagnostic pitfall and cause misdiagnosis of tufted folliculitis (Fig. 15.4).27,28
alopecia areata. It should be kept in mind that these two Ultraviolet-enhanced trichoscopy, first described in
diseases, trichotillomania and alopecia areata, relatively 2011,20 is a new method, which may aid in the identification
commonly coexist,21 what makes trichoscopic differential of tinea capitis. The method is based on the combination
diagnosis even more challenging (Fig. 15.3). of Wood’s light and trichoscopy (Fig. 15.5).20
Tinea Capitis
CICATRICIAL ALOPECIA
Trichoscopy has a major benefit over mycological culture
in that it gives immediate results. The typical trichoscopy Lichen Planopilaris
features of tinea capitis are comma hairs22 and corkscrew Trichoscopy of lichen planopilaris depends on the stage
hairs,23 the latter being more common in patients with of disease. In the active, inflammatory phase of the dis-
dark skin phototypes.24 These typical hair shaft structure ease, the predominant trichoscopy feature is perifollicular
Trichoscopy 303
Fig. 15.5: Ultraviolet (UV)-enhanced trichoscopy is performed with

a dermoscope equipped with a UV light source, which overlaps with
Wood’s lamp wavelength.
A B
Figs. 15.6A and B: Lichen planopilaris. (A) Perifollicular scaling (20-fold magnification). (B) The scales entangle the hair shaft up to a few
millimeters above the hair follicle opening—“tubular scaling” (70-fold magnification).
scaling. Scales migrate along the hair shaft and form a are considered a residue of conduced perifollicular fibrosis.31
tubular structure, which covers the proximal portion of the These are irregularly shaped, small whitish areas. These
emerging hair shaft (tubular scaling or tubular perifolli are slightly bigger compared to yellow and black dots and
cular hyperkeratosis).7,29 This feature is a characteristic, have a tendency to merge and form milky-red areas (fibrosis
but not pathognomonic, of Lichen plano pilaris (LPP). It of the recent onset) and white areas (late-stage fibrosis).
may also be observed in other folliculocentric alopecias, These white dots have to be distinguished from small
in particular, in folliculitis decalvans. Round, perifollicu- pinpoint white dots, which represent empty follicular ostia
lar, blue–gray, or violaceous areas surrounding empty hair in patients with dark skin phototypes (Figs. 15.6A and B).32
follicle openings in a targetoid pattern were described in
patients with dark phototypes.30 Elongated perifollicular Frontal Fibrosing Alopecia
blood vessels may be a manifestation of the ongoing
inflammatory process. Frontal fibrosing alopecia is considered a subtype of
In the late fibrotic stage of the disease, the dominating lichen planopilaris. Thus, these two diseases share some
trichoscopy presentations are white dots, milky-white common trichoscopy features. The main trichoscopy find-
areas, and white areas. White dots in lichen planopilaris ings in frontal fibrosing alopecia include lack of follicular
A B
Figs. 15.7A and B: (A) Frontal fibrosing alopecia. Mild perifollicular scaling, lonely hair, and areas with no follicular openings in the frontal scalp.
(B) Trichoscopy of the eyebrow area shows multiple hair follicle openings (brownish dots).
openings and minor perifollicular scaling. Perifollicular

erythema is not common and is considered a feature of
active disease.33 There is a strong predominance of folli
cular openings with only one hair at the hair-baring
margin. Lonely hair, defined as single terminal hairs sur-
rounded by cicatricial alopecia, may be observed clinically
as well as in trichoscopy.34
In the eyebrow area, trichoscopy shows regularly dis-
tributed reddish or gray dots (early disease) or an area lack-
ing follicular openings (late disease) (Figs. 15.7A and B).2
Folliculitis Decalvans
As in all other types of cicatricial alopecia, trichoscopy Fig. 15.8: Folliculitis decalvans. Hair tufts surrounded by yellowish
will depend on the stage of disease. In early, active scales.
disease, trichoscopy shows tufts of five or more hairs
emerging from one follicular opening. The hair tufts
are surrounded by tubular perifollicular scaling. Unlike disease. Thus, the trichoscopy abnormalities do not seem
lichen planopilaris, where the scales are usually white, to be strictly associated with follicular openings. The most
in folliculitis decalvans, the tubular scaly structures characteristic trichoscopy features of active discoid lupus
appear yellowish. This results from the purulent con- erythematosus are thick arborizing vessels, large yellow
tent in these structures. dots (keratotic plugs), scattered dark-brown discolo
The tufts may be surrounded by perifollicular epider- ration, and blue-gray dots.29,36 Large yellow dots in DLE
mal hyperplasia, which may be arranged in a starburst are darker compared to other diseases, usually dark yel-
pattern (starburst sign).35 Other trichoscopy features of low to yellow brown in color. Yellow dots with radial, thin
active folliculitis decalvans are follicular pustules, yel- arborizing vessels emerging from the dots are considered
low discharge, and perifollicular arrangement of blood highly characteristic of late discoid lupus erythematosus
vessels.29 In long-lasting lesions, white, fibrotic areas (DLE) lesions and were called “red spider in yellow dot”
predominate in trichoscopy images (Fig. 15.8).29 by Rakowska et al.29
Long-lasting, inactive DLE lesions differ from active
Discoid Lupus Erythematosus lesions. They are characterized by the presence of struc-
Despite being categorized as primary cicatricial alopecia, tureless milky-red or white areas and lack of follicular
discoid lupus erythematosus is not a “true” folliculocentric openings (Figs. 15.9A and B).
Trichoscopy 305
A B
Figs. 15.9A and B: Discoid lupus erythematosus. (A) Thick arborizing vessels. (B) In the eyebrow area, the disease may present with a strawberry
pattern.
REFERENCES 14. Rakowska A, Slowinska M, Olszewska M, et al. New trichos-

copy findings in trichotillomania: flame hairs, V-sign,
1. Rudnicka L, Olszewska M, Rakowska A, et al. Trichoscopy: hook hairs, hair powder, tulip hairs. Acta Derm Venereol.
a new method for diagnosing hair loss. J Drugs Dermatol. 2014;94(3):303-6.
2008;7(7):651-4. 15. Abraham LS, Torres FN, Azulay-Abulafia L. Dermoscopic
2. Rudnicka L, Olszewska M, Rakowska A. Atlas of Tricho clues to distinguish trichotillomania from patchy alopecia
scopy: Dermoscopy in Hair and Scalp Disease. London: areata. An Bras Dermatol. 2010;85(5):723-6.
Springer; 2012. pp. xiv, 507. 16. Gallouj S, Rabhi S, Baybay H, et al. [Trichotemnomania
3. Mubki T, Rudnicka L, Olszewska M, et al. Evaluation and diag- associated to trichotillomania: a case report with empha-
nosis of the hair loss patient: part II. Trichoscopic and labora- sis on the diagnostic value of dermoscopy]. Ann Dermatol
tory evaluations. J Am Acad Dermatol. 2014;71(3):431e1-11. Venereol. 2011;138(2):140-1.
4. Orasan MS, Bolfa P, Coneac A, et al. Topical products for 17. Lee DY, Lee JH, Yang JM, et al. The use of dermoscopy for
human hair regeneration: a comparative study on an ani- the diagnosis of trichotillomania. J Eur Acad Dermatol
mal model. Ann Dermatol. 2016;28(1):65-73. Venereol. 2009;23(6):731-2.
5. Rakowska A. Trichoscopy (hair and scalp videodermo 18. Inui S, Nakajima T, Nakagawa K, et al. Clinical significance
scopy) in the healthy female. Method standardization and of dermoscopy in alopecia areata: analysis of 300 cases. Int
norms for measurable parameters. J Dermatol Case Rep. J Dermatol. 2008;47(7):688-93.
2009;3(1):14-9. 19. Ihm CW, Han JH. Diagnostic value of exclamation mark
6. Vogt A, McElwee K, Blume-Peytavi U. Biology of the hair hairs. Dermatology. 1993;186(2):99-102.
follicle. In: Blume-Peytavi U, Tosti A, Whiting D, Trüeb R 20. Rudnicka L, Olszewska M, Rakowska A, et al. Trichoscopy
(Eds). Hair; from Basic Science to Clinical Application. Ber- update 2011. J Dermatol Case Rep. 2011;5(4):82-8.
lin, Germany: Springer-Verlag; 2008. pp. 1-22. 21. Sah DE, Koo J, Price VH. Trichotillomania. Dermatol Ther.
7. Rudnicka L, Olszewska M, Rakowska A, et al. Trichoscopy 2008;21(1):13-21.
update 2011. J Dermatol Case Rep. 2011;5(4):82-8. 22. Slowinska M, Rudnicka L, Schwartz RA, et al. Comma hairs:
8. Torres F, Tosti A. Trichoscopy: an update. G Ital Dermatol a dermoscopic marker for tinea capitis: a rapid diagnostic
Venereol. 2014;149(1):83-91. method. J Am Acad Dermatol. 2008;59(5 Suppl):S77-9.
9. Olszewska M, Warszawik O, Rakowska A, et al. Methods of 23. Pinheiro AM, Lobato LA, Varella TC. Dermoscopy findings
hair loss evaluation in patients with endocrine disorders. in tinea capitis: case report and literature review. An Bras
Endokrynol Pol. 2010;61(4):406-11. Dermatol. 2012;87(2):313-4.
10. Lacarrubba F, Dall’Oglio F, Rita Nasca M, et al. Videoder- 24. Hughes R, Chiaverini C, Bahadoran P, et al. Corkscrew hair:
matoscopy enhances diagnostic capability in some forms of a new dermoscopic sign for diagnosis of tinea capitis in
hair loss. Am J Clin Dermatol. 2004;5(3):205-8. black children. Arch Dermatol. 2011;147(3):355-6.
11. Rudnicka L, Rakowska A, Kerzeja M, et al. Hair shafts in 25. Brasileiro A, Campos S, Cabete J, et al. Trichoscopy as an
trichoscopy: clues for diagnosis of hair and scalp diseases. additional tool for the differential diagnosis of tinea capitis.
Dermatol Clin. 2013;31(4):695-708, x. Br J Dermatol. 2016; 175:113-21.
12. Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the eval- 26. Sandoval AB, Ortiz JA, Rodriguez JM, et al. [Dermoscopic
uation of hair and scalp disorders. J Am Acad Dermatol. pattern in tinea capitis]. Rev Iberoam Micol. 2010;27(3):151-2.
2006;55(5):799-806. 27. Baroni A, Ruocco E, Aiello FS, et al. Tinea capitis mimick-
13. Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad ing tufted hair folliculitis. Clin Exp Dermatol. 2009;34(8):
Dermatol. 2012;67(5):1040-8. e699-701.
28. Tangjaturonrusamee C, Piraccini BM, Vincenzi C, et al. topathologic correlation. J Am Acad Dermatol. 2010;63
Tinea capitis mimicking folliculitis decalvans. Mycoses. (4):721-2.
2011;54(1):87-8. 33. Toledo-Pastrana T, Hernandez MJ, Camacho Martinez FM.
29. Rakowska A, Slowinska M, Kowalska-Oledzka E, et al. Perifollicular erythema as a trichoscopy sign of progres-
Trichoscopy of cicatricial alopecia. J Drugs Dermatol. sion in frontal fibrosing alopecia. Int J Trichology. 2013;
2012;11(6):753-8. 5(3):151-3.
30. Duque-Estrada B, Tamler C, Sodre CT, et al. Dermoscopy 34. Tosti A, Miteva M, Torres F. Lonely hair: a clue to the diag-
patterns of cicatricial alopecia resulting from discoid lupus nosis of frontal fibrosing alopecia. Arch Dermatol. 2011;
erythematosus and lichen planopilaris. An Bras Dermatol. 147(10):1240.
2010;85(2):179-83. 35. Rakowska A, Slowinska M, Kowalska-Oledzka E, et al.
31. Miteva M, Tosti A. Dermoscopy-guided scalp biopsy in Trichoscopy in cicatricial alopecia. J Drugs Dermatol. 2012;
cicatricial alopecia. J Eur Acad Dermatol Venereol. 2013; 11(6):753-8.
27(10):1299-303. 36. Miteva M, Tosti A. Dermoscopic features of central cen-
32. Abraham LS, Pineiro-Maceira J, Duque-Estrada B, et al. trifugal cicatricial alopecia. J Am Acad Dermatol. 2014;
Pinpoint white dots in the scalp: dermoscopic and his- 71(3):443-9.
CAPILLAROSCOPY 16
Emilia Noemi Cohen Sabban
“Capillaroscopy is a noninvasive, safe, in vivo study of the capillaries morphology,
which can be assessed by using a magnifying system, enabling the early recognition of morphological
and functional abnormalities in microcirculation, the most distal area of the circulatory tree.
Cutaneous microcirculation is easy to explore; it is localized at dermal level, and composed of two
interconnected plexuses: the subpapillary plexus or superficial plexus, parallel to the epidermis,
from which capillary loops branch up; and the deep, dermohypodermal plexus.
In vivo study of the capillaries is performed preferably in the nailfold, since in this anatomical
region the capillaries lie parallel to the cutaneous surface as opposed to what happens in other skin areas,
where they lie perpendicularly, and consequently appear as red dots on a light background.”
Capillaroscopy 309
INTRODUCTION
Capillaroscopy is a noninvasive, safe, in vivo study of the
capillaries morphology, which can be assessed by using a
magnifying system, enabling the early recognition of mor
phological and functional abnormalities in microcircula
tion, the most distal area of the circulatory tree.
Cutaneous microcirculation is easy to explore; it is
localized at dermal level, and composed of two intercon
nected plexuses: the subpapillary plexus (SP) or superficial
plexus, parallel to the epidermis, from which capillary
loops branch up; and the deep, dermohypodermal plexus.1
In vivo study of the capillaries is performed preferably
in the nailfold, since in this anatomical region the capil
laries lie parallel to the cutaneous surface as opposed to
Fig. 16.1: A dermoscope (Dermlite polarized light 10×) attached to a
what happens in other skin areas, where they lie perpen
photographic camera.
dicularly, and consequently appear as red dots on a light
background.2
Nailfold capillaroscopy (NC) consists, therefore, in visualization of moving images but also in sharpness,
the direct visualization of the distal line of the periungual scope, detail, register, and imaging study.4
capillaries. Dermatologists, having been trained in the use of the
The procedure was described more than a century ago, dermoscope for the diagnosis of melanocytic and non
but only in recent decades it has gained popularity and melanocytic lesions, perform capillaroscopy with this
come to play an important role in the diagnosis and moni instrument attached to a photographic camera to record
toring of different illnesses. images, like the ones included in this chapter (Fig. 16.1).
Some conditions that cause changes in the shape A study comparing VC with dermoscope concluded that
and density of the capillaries are systemic sclerosis (SSc), dermoscopy was efficient enough to identify pathogno
dermatomyositis (DM), mixed connective tissue disease monic changes.5
(MCTD), Raynaud’s phenomenon (RP), overlap syndro It is important to remark that this instrument is inexpen
mes, systemic lupus erythematosus (SLE), as well as condi sive, easy to use and carry, and that with proper training, it
tions involving microcirculation such as diabetes mellitus may substitute more sophisticated devices and systems.6,7
(DbM) and hypertension (HT).3
This procedure has the following advantages:
•• Harmless, noninvasive
NORMAL CAPILLAROSCOPY
•• Repeatable/reproducible Even though normality has not yet been defined due to
•• Low cost individual variations, it could be said that the normal
•• High sensitivity aspect is characterized by a regular capillary distribution
•• Good specificity of homogeneous size. This arrangement has been des
•• Easy interpretation. cribed as the “capillary comb” or “palisade” (Fig. 16.2).
There are several instruments used for the observa Subtle morphological alterations, such as tortuosity, are
tion of capillaries in the periungual fold, such as a stereo common and lack pathological value.
microscope, an optic microscope, an ophthalmoscope, a In healthy subjects, the capillary density, defined as
40× magnifier, and an adaptor to obtain images. At pres the number of loops per surface unit, is 9–17 capillary
ent, there are also videocapillaroscopes with a software per linear millimeter; at this level, the capillaries have
that allows dynamic studies of microcirculation by count their main axis parallel to the cutaneous surface, as has
ing capillary number and assessment of the capillary loops already been mentioned. Each papilla has 1–3 U-shaped
and their branches. or hairpin capillary loops, in which it is possible to visua
According to some authors, videocapillaroscopy (VC) lize the erythrocyte column. The length of the loops varies
outperforms conventional capillaroscopy not only in the between 200 and 400 µm.6
Fig. 16.2: Normal capillaroscopy with the typical “capillary comb” or Fig. 16.3: Subpapillary plexus. Vessels with their main axis perpendi
“palisade” arrangement. cular to the capillaries.
There are interindividual variations depending on a

number of specific factors such as age, race, sex, physical
type, occupation, and differences between fingers of the
same patient. For example, the capillaries of the second
finger are shorter than those of the fourth and fifth fingers.9
In patients with dark skin or high phototypes, the cuta
neous pigmentation absorbs much more light, decreasing
visibility, which renders the technique impracticable.1
Manual laborers, due to constant microtraumatism,
have a slightly modified capillaroscopic pattern, with tor
tuous capillaries or traumatic microhemorrhages, which
are considered normal findings among them. Constant
manicures and cuticle trimming are associated with the
appearance of very short capillaries or multiple traumatic
hemorrhages without pathological correlation.10
Fig. 16.4: Subpapillary plexus. Vessels with their main axis perpendi
cular to the capillaries.
We have previously described personal variations,
depending on the individual, but there are also external
factors that may affect the results of this procedure. Among
these, we must mention environmental temperature; the
Each capillary loop has three parts, an arterial afferent
lower the temperature, the lower the number of capillar
branch (A), around 5–20 µm diameter, and another one
ies, which may be mistaken for loss of capillaries or avas
venous efferent (V), longer and thicker, which reaches cular areas.
8-30 µm. Index V:A < 2.1. The transition or middle area The presence of nail polish traces may simulate inexis
corresponds to the union of the two. Both branches run tent hemorrhages, so it is recommended to suspend its
parallel and straight, although some tortuosity is possible.8 application 15–21 days prior to NC.8
The SP under the papillary dermis appears like a mesh Lastly, smoking is forbidden to the patient, at least
or a network of larger vessels with their main axis perpen 2 hours prior to the study.1
dicular to the capillaries. In prepubers and elderly people, In brief, in healthy subjects there may be isolated
whose skin is more translucent, it is much more visible abnormalities concerning the distribution, morphology
than in young adults, where it is clear in one-third of (Chart 16.1) and orientation of the capillaries, which must
healthy population (Figs. 16.3 and 16.4). be taken into account to avoid interpretation mistakes.
Capillaroscopy 311
Chart 16.1: Most frequent morphological variations in healthy

individuals.
Open 76% Tortuous 23% Crossed 1%

Adapted from da Silva LSM, Lima ARAG, Pucinelli MLC, et al. Capila
roscopia panorâmica periungueal e sua aplicação em doenças reu
máticas. Rev Assoc Med Bras. 1997;43(1):69-73.
INDICATIONS
At present capillaroscopy is indicated in the following cases:
•• To distinguish between primary and secondary RPs Fig. 16.5: Technique mistake.
•• As adjuvant technique for the diagnosis of diseases
such as SSc, SLE, DM, and MCTD
•• For the differentiation between active and quiescent the loss of its normal architecture but also the extent of
diseases such destructuration; quantifying the number of micro
•• For follow-up hemorrhages and megacapillaries rather than consider
•• For prescription of treatment, dosage adjustment ing just their presence. All this makes it possible to find a
•• Because of its prognosis value (the presence of dilated capillaroscopic score, which is, in turn, useful for disease
capillaries in RP is highly indicative of evolution follow-up.12,13
toward SSc).3,5
MORPHOLOGICAL ALTERATIONS
TECHNIQUE
In capillaroscopy, we can find changes in number, mor
Capillaroscopy is not the same on all fingers; on the cont phology, and architecture of the microcirculation.
rary, the best results are obtained from the observation of The most frequent morphological alterations are tor
the fourth and fifth fingers, owing to greater skin transpa tuosity, homogeneous vasodilation, microhemorrhages
rency. The nondominant hand is preferred because its and capillary thrombosis, and neoangiogenesis.14
capillaries are longer and the SP is more visible. No pres
sure must be placed on the skin, so as not to modify the Tortuosity
image (Fig. 16.5). The optimal magnification is between It is frequent in healthy subjects and has little diagnostic
30× and 100×. The patients must feel comfortable and value, since the existence of tortuosity does not necessarily
relaxed, their hands warm, to avoid mistakes.11 imply microcirculation alterations (Figs. 16.6 and 16.7).
Only when tortuosity appears in >20% of the capi
QUALITATIVE AND QUANTITATIVE llaries, it is considered pathological and found in SSc and
related disorders (MTCD and DM), SLE, and DbM.
CAPILLAROSCOPY
It may be considered a sign of neoangiogenesis, e.g. in
Although initially capillaroscopy consisted in a qualitative psoriasis.
description, focusing on the morphological abnormalities
of the capillaries, it is precisely in SSc and related disorders Capillary Dilation
that its findings started to be quantified, in order to cor Normal and dilated capillaries may coexist within a
relate them to the disease activity, its evolution and prog papilla. A capillary diameter of >20 µm defines a dilated
nosis based on the involvement of the internal organs, etc. capillary, which, depending on shape, may be classified
In this manner, quantitative capillaroscopy was born as homogeneous or irregular. Dilated capillaries may be
more recently, focusing on the number and caliber of the found in multiple conditions such as SSc, DM, MTCD,
capillaries besides their morphology; considering not only RP, DbM, acrocyanosis, and hereditary hemorrhagic
Fig. 16.6: Tortuosity. Fig. 16.7: Tortuosity. Subpapillary plexus visualization.
Fig. 16.8: Capillary dilation. Fig. 16.9: Capillary dilation.
telangiectasia or Rendu Osler’s disease, where, apart from first manifestation of disease microvascular involvement,
variations in size, a wide range of capillary morphologies then followed by the other alterations composing this
and orientations may be observed (Figs. 16.8 and 16.9). pattern.
A homogeneous enlargement of capillary diameter Furthermore, their presence acquires a predictive value
over 50 µm is known as megacapillary (Fig. 16.10); whereas since in patients with RP whose capillaroscopy is almost
within the irregular type there is the microaneurysm, which normal, the isolated presence of two or more dilated capil
is the circumscribed enlargement in a capillary diameter. laries in one or two digits or of a megacapillary is highly
Maricq et al. have put forward a classification of vasodi indicative of an evolution toward scleroderma with 83.1%
lation in grades, where grade 1 corresponds to no dilation sensitivity and 100% specificity.9,17
whatsoever; grade 2 to moderate dilation (4–10 times the
regular diameter), and grade 3 is >10 times the normal size Microhemorrhages and Capillary Thrombosis
or megacapillary.15,16 Microhemorrhages manifest capillary injury, whether
Megacapillaries are among the early alterations of post-trauma in normal subjects (manicure and onychoph
the “scleroderma (SD) pattern”, and in some cases the agia) or in patients with disorders within the scleroderma
Capillaroscopy 313
Fig. 16.10: Megacapillary. Fig. 16.11: Different examples of microhemorrhages.
Capillary Density
The regular number of capillaries is 9–17 per linear mm
(10–30 per mm2) in adults and 5–9 per mm in children.
Fewer than 5 capillaries per mm is considered a decrease
in capillary number.
The loss of capillaries correlates with the duration of
the disease and this applies not only to SSc but also to DM,
DbM, and HT.
If an area larger than 500 µm (0.5 mm) is affected by
capillary loss, it is called “avascular area,” a component of
the SD pattern, which first insinuates in the active pattern,
but is highly typical of the late one. Its presence has a prog
nostic value for progressive and more aggressive disease,
involvement of the internal organs, etc., which makes it
Fig. 16.12: Avascular areas. Neoangiogenesis at the periphery of the useful as a warning signal (Fig. 16.12). Avascular areas also
avascular areas. Neoformed vessels are thinner, more branched, and represent the most important risk factor for the develop
with different shapes.
ment of cutaneous ulcers (a frequent vascular complication
of SSc), as much as for its healing and for the prescription
of aggressive treatments to improve angiogenesis.18
spectrum, due to its close relation with the dilation of the
capillary loops. Capillary Neoangiogenesis
Capillary erythrocyte extravasation deposits inside the It is defined by the presence of four or more capillary loops
cuticle, distally to the compromised vessel. A “comb-like in one single dermal papillae and is one of the alterations
hemorrhage” has been described in antiphospholipid syn present in the SD pattern, indicative of DM and MCTD,
drome. but also seen in DbM, psoriasis and cutaneous tumors. It
Both thrombosis and microhemorrhages are dark may present in normal subjects, but in isolation.
masses, but it is their shape that tells them apart. Recent Neoangiogenesis is usually found in the periphery of
hemorrhages have a crescent shape, as opposed to older avascular areas, since it reflects an attempt at compensat
ones, which are more rounded; besides, in thrombosis the ing capillary loss and is generally accompanied by some
dark stain resembles the shape of the capillary loop, which irregularity and increase in capillary size. The newly formed
does not happen in hemorrhages (Fig. 16.11).4 vessels (neoformed vessels) are thinner, more branched
Table 16.1: The SD pattern.

Pattern Predominant changes Less prominent
Early Dilated capillaries and Microhemorrhages
megacapillaries
Active Dilated capillaries, megacapillaries Capillary loss
and microhemorrhages
Late Capillary loss, avascular areas, Dilation and
angiogenesis, ramification, megacapillaries
disorganization
for the development of scleroderma, involvement of inter

nal organs, etc. The sensitivity of the SSc classification cri
teria of the American College of Rheumatology increased
from 67% to 99% with the recognition of the SD capillaro
Fig. 16.13: Loss of architecture. Disorganization. scopic pattern. There is a correlation between clinical
manifestations, serologic markers, and capillaroscopy.16
It takes into account the dilated capillaries and mega
capillaries, microhemorrhages, avascular areas and angio
genesis, and ramified vessel.19 Three evolutionary stages
have been described according to which of these elements
prevails in the capillaroscopic scenario (Table 16.1).20
•• Early SD pattern: Prevalence of dilated and megacapi
llaries and few microhemorrhages
•• Active pattern: Dilated and megacapillaries, frequent
microhemorrhages and little capillary loss and onset
of the loss of normal architecture. It has an evolving
picture (Fig. 16.14)
•• Late pattern: Severe capillary loss—extensive avascu
lar areas, neoangiogenesis with arborizing capillaries
and architectural disorganization.
Therefore, it is possible to infer that the longer the
Fig. 16.14: Active scleroderma pattern. duration of the disease, the smaller the number of dilated
capillaries and microhemorrhages.
Based on the SD capillaroscopic pattern, it is estimated
and with different shapes, e.g., arborizing or “bushy capi that about ∼15% of patients go from a primary RP (PRP) to
llary” in DM, glomerular, and corkscrew (see Fig. 16.12). a secondary RP (SRP) within 29.4 ± 10 months.21
Those patients with PRP who will develop SRP to SSc
Loss of Architecture can be detected at present before the disease manifests
It is the characteristic of advanced SSc and includes clinically.22 Moreover, in patients without any clinical sign
changes in capillary distribution, shape, diameter, and of the disease, with typical SD capillaroscopic changes and
orientation axis. There is a clear polarity alteration, result positive antibodies, it is possible today to predict that 47%
ing in the disorganization of the normal order of the capi of patients will develop SSc within 5 years; 69% in 10 years,
llary bed (Fig. 16.13).4 and 70% in 15 years.23 In patients with an early pattern
rapidly progressing to an active pattern, in approximately
less than a year, close monitoring is recommended, since
SCLERODERMA PATTERN
evidence suggests a high risk of progression to a late or
The SD capillaroscopic pattern is considered a marker of advanced stage, which in turn correlates with clinical
vascular injury with a high positive predictive value (PPV) manifestations of SSc.24
Capillaroscopy 315
Table 16.2: Capillaroscopic patterns.

Normal pattern:
• Regular palisade pattern
• Homogeneous distribution
• Normal density, no loss of capillaries.
SD pattern:
• Capillary dilation and megacapillaries
• Microhemorrhages
• Avascular areas.
SLE pattern:
• Tortuosity
• Elongation and curling of capillaries: “Meandering capillaries”
• Capillaries with dilation of afferent branch
• SP prominent. Fig. 16.15: Patient with systemic sclerosis, Raynaud´s phenomenon,
digital ulcers, cutaneous involvement, and capillaroscopic scleroderma
Traumatic microangiopathy: pattern.
• Short capillaries
• Microhemorrhages.
and systemic treatment. Recently, the capillaroscopic skin
(SD: Scleroderma; SLE: Systemic lupus erythematosus; SP: Subpapillary
plexus). ulcer risk index has been validated as a useful tool to pre
dict the development of new ulcers and/or persistence of
unhealed lesions, within 3 months of capillaroscopic eva
CONSIDERATIONS FOR SPECIFIC luation, with statistically significant sensitivity, specificity,
PATHOLOGIES and PPV.26,27
The most validated capillaroscopic pattern is the SD pat Dermatomyositis

tern, but there are others, although not equally typical It has an SD pattern indistinguishable from SSc, although
(Table 16.2). The SD pattern is a characteristic of different according to some authors, the changes in morphology
diseases, but it differs in the percentage of appearance in and architecture are not only as significant as in SSc but
them:4,19 also faster and more progressive, especially as regards
•• 80–100% in SSc microhemorrhages, avascular areas, and angiogenesis.
•• 55–100% in DM However, no relevant differences from SSc were found
•• 25% polymyositis with reference to homogeneous dilation and megacapil
•• 40–80% MTCD. laries (Fig. 16.16).28
Systemic Sclerosis As regards angiogenesis, the presence of “bushy capil
laries” or neoformed capillaries with arborizing shape is
The SD pattern is characteristically found at different stages
the characteristic of this disease (Fig. 16.17).29,30 Finally, it
of the disease (Fig. 16.15). There is a correlation between is noteworthy that capillaroscopic changes reflect disease
plasma levels of endothelin-1 (ET-1), clinical manifes activity, and a correlation has been found between muscle
tations [e.g. digital ulcers (DU)], and capillaroscopic involvement, phosphocreatine kinase serum values, and
changes (capillary density, ramified, and dilated capilla capillary loss, as opposed to microhemorrhages, which
ries) in these patients. The highest plasma levels for ET-1 were associated with cutaneous lesions. The capillary dila
were detected in the advanced stage or late SD pattern, tion, microhemorrhages, and the capillary loss decreased
characterized by loss of capillaries and important tissue after treatment.31
fibrosis.25
Digital ulcers, present in 50% of scleroderma patients, Systemic Lupus Erythematous
are the cause of high morbidity, limitation, and impact the In 50% of lupus patients, capillaroscopic findings have SLE
quality of life, with pain and discomfort, demanding local pattern, and in 73.3% of cases the antinuclear antibodies
Fig. 16.16: Patient with dermatomyositis. Erythema on the face and Fig. 16.17: Dermatomyositis. Capillaroscopic scleroderma pattern with
anterior neck. Gottron papules on the dorsum of the hand. Sclero avascular areas and neoformed vessels.
derma pattern with dilated capillaries and microhemorrhages.
Fig. 16.18: Patient with systemic lupus erythematosus. Loss of the Fig. 16.19: Systemic lupus erythematosus. Loss of the most distal line
most distal line of capillaries. Malar erythema. Raynaud´s phenomenon. of capillaries, dilated capillaries, elongated and tortuous, subpapillary
Dilated capillaries, elongated and tortuous, subpapillary plexus visua plexus visualization, and meandering capillaries.
lization.
are positive. In 30% of cases, capillaroscopy is nonspecific; In a study, it was observed that out of 30 lupus patients,
next in frequency comes SD pattern in 13.3% of cases, and 80% had dilated capillaries, and 6.6% were megacapilla
lastly, for 6.6% cases the pattern is normal (Fig. 16.18).19 ries, while 43% were elongated. Tortuous capillaries were
The characteristic SLE pattern consists in dilated capi recorded in 70% of cases and SP was prominent in 60%
llaries, elongated, and tortuous, some of them crossing cases. Finally, microhemorrhages were present in 16.6%
each other or “meandering”’ (a combined effect of waving of studied cases.19
and curling) and others arborized (Fig. 16.19). Also, in this An interrelation has been detected in patients with SLE
disease, SP may be prominent, and the afferent branch between clinical activity (Systemic Lupus Erythematosus
may be highly dilated. The absence of the most distal line Disease Activity Index), capillaroscopic score, and vascu
of capillaries has also been described.4,32 lar endothelial activation markers [vascular endothelial
Capillaroscopy 317
Fig. 16.20: Patient with mixed connective tissue disease. Fig. 16.21: Dilated capillaries on an edematous background and
microhemorrhages.
capillaroscopic changes are observed, like arborizing cap

illaries similar to those of DM (Figs. 16.20 and 16.21).4,36-38
Rheumatoid Arthritis (RA)

The most common capillaroscopic image consists in the
visualization of the SP on a light background, due to the
presence of edema (Fig. 16.22). Capillaries may be tortu
ous and dilated.
Out of 62 RA patients, 30.6% presented with RP. With
regard to the capillaroscopic pattern, SP was prominent in
69% cases, while 58% cases showed elongated capillaries.
In 14.5% cases, the capillaroscopic pattern corresponded
to scleroderma-like pattern or SD pattern.39
Psoriasis
Fig. 16.22: Capillaroscopy in a patient with rheumatoid arthritis:
In this case too, SP visualization is a main finding too,
visualization of the subpapillary plexus on a light background.
but also the capillaries are shorter and their number
increased.40
growth factor (VEGF), ET-1, sTM, and sE-selectina].33 In a
study including 80 patients with SLE, 92.5% cases had cap Diabetes
illaroscopic alterations. In 41.25% cases, capillaroscopy Microvascular involvement results in lower density of
was almost normal or presenting slight changes, and in capillaries with diminished blood flow.4
58.75% cases, the changes observed were mild/severe.34
The higher the lupus activity index, the more active the CONCLUSION
endothelial markers (VEGF) and the higher the capillaro
scopic score.35 Nailfold capillaroscopy is a procedure yields a fast,innoc
uous, and affordable diagnosis, which reaches extremely
Mixed Connective Tissue Disease high levels of sensitivity and specificity in diseases such
In almost 40% of cases, capillaroscopic changes correspond as RP and SSc. It also has prognostic value and contrib
to SD pattern, while in the rest, the changes are rather utes to a therapeutic response follow-up. Patients with
nonspecific.19 The more active the disease, the more the this kind of diseases demand an interdisciplinary team,
in which dermatologists, rheumatologists, and clinicians 18. Alivernini S, De Santis M, Tolusso B, et al. Skin ulcers in sys
may count on this very helpful technique. It is important temic sclerosis: determinants of presence and predictive
factors of healing. J Am Acad Dermatol. 2009;60(3):426-35.
to know the capillaroscopic patterns to acquire and trans
19. Lambova SN, Müller-Ladner U. Capillaroscopic pattern in
mit a common language among physicians from different systemic lupus erythematosus and undifferentiated con
specializations for the benefit of our patients. nective tissue disease: what we still have to learn? Rheuma
tol Int. 2013;33(3):689-95.
20. Cutolo M, Sulli A, Pizzorni C, et al. Nailfold videocapillaro
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2. Martínez Sánchez FG. Historia de la capilaroscopía. Semin model based on nailfold capillaroscopy for identifying Ray
Fund Esp Reumatol. 2010;11(Supl 1):3-4. naud’s phenomenon patients at high risk for the develop
3. Cutolo M, Sulli A, Smith V. How to perform and inter ment of a scleroderma spectrum disorder: PRINCE (prog
pret capillaroscopy. Best Pract Res Clin Rheumatol. nostic index for nailfold capillaroscopic examination).
2013;27(2):237-48. Arthritis Rheum. 2008;58(7):2174-82.
4. Leroux MB. Actualización: Capilaroscopia y Videocapi 22. Olivé A, García-Melchor E. On Raynaud’s phenomenon.
laroscopia su utilidad para el Dermatólogo Práctico. Med Clin. 2010;134(10):470.
PIEL-LATINOAMERICANA 17/04/2009 -AÑO IX- EDI 23. Cutolo M, Smith V. State of the art on nailfold capillaro
CION 337 |Septiembre, 06 – 2013. scopy: a reliable diagnostic tool and putative biomarker in
5. Dogan S, Akdogan A, Atakan N. Nailfold capillaroscopy in rheumatology? Reumatology. 2013;52(11):1933-40.
systemic sclerosis: Is there any difference between video 24. Sulli A, Pizzorni C, Smith V, et al. Timing of transition
capillaroscopy and dermatoscopy? Skin Res Technol. between capillaroscopic patterns in systemic sclerosis.
2013;19 (4):446-9. Arthritis Rheum. 2012;64(3):821-5.
6. Bergman R, Sharony L, Schapira D, et al. The handheld der 25. Sulli A, Soldano S, Pizzorni C, et al. Raynaud’s phenome
matoscope as a nail-fold capillaroscopic instrument. Arch non and plasma endothelin: correlations with capillaro
Dermatol. 2003;139:1027-30. scopic patterns in systemic sclerosis. J Rheumatol. 2009;36
7. Muroi E, Hara T, Yanaba K, et al. A portable dermatoscope (6):1235-9.
for easy, rapid examination of periungual nailfold capillary 26. Sebastiani M, Manfredi A, Lo Monaco A, et al. Capillaro
changes in patients with systemic sclerosis. Rheumatol Int. scopic Skin Ulcers Risk Index (CSURI) calculated with
2011;31(12):1601-6. different videocapillaroscopy devices: how its predic
8. da Silva LSM, Lima ARAG, Pucinelli MLC, et al. Capi tive values change. Clin Exp Rheumatol. 2013;31(2 Suppl
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9. Petry DG, Terreri MT, Len CA, et al. Nailfold capillaroscopy of capillaroscopic skin ulcer risk index in systemic sclerosis:
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Fund Esp Reumatol. 2010;11(Supl 1):1-2. vascular involvement in DM and SS. A preliminary study by
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and systemic sclerosis. Arthritis Rheum. 2010;62:595-604. between nail-fold capillary findings and disease activity in
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related disorders. Arthritis Rheum. 1981;24(9):1159-65. vation markers and disease activity. Scand J Rheumatol.
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17
REFLECTANCE
CONFOCAL MICROSCOPY
Giovanni Pellacani, Caterina Longo, Elvira Moscarella
“Reflectance confocal microscopy (RCM) is a noninvasive imaging technique that produces
horizontal images of the skin in a cellular level resolution and in real time.
This instrument uses a diode laser with a nearinfrared wavelength of 830 nm that penetrates
the skin up to a depth of 200–300 μm, which corresponds to the superficial dermis.
The construction of the images is dependent on the refractive index of the tissue,
which changes according to its chemical and molecular structures.
The refractive structures, such as melanin, keratin, collagen fibers, inflammatory cells,
and blood cells, appear in white color with different degrees of intensity on the gray-scale,
melanin and melanosomes being the most important sources of contrast.”
Reflectance Confocal Microscopy 323
17. 1 THE UTILITY OF CONFOCAL MICROSCOPY IN THE

DIAGNOSIS OF SUPERFICIAL SPREADING MELANOMA
Giovanni Pellacani, Nathalie De Carvalho
Melanoma is the most worrisome skin tumor and its early In the study of melanocytic lesions, some consider
diagnosis reflects on a higher rate of survival, remaining ations must be taken regarding the classification of con
the main key to guarantee a lower risk of mortality. Dermo focal patterns for each of the three layers evaluated. In the
scopy enhances the diagnosis of melanoma but, in early epidermis (stratum spinosum/granulosum), regularity
stages, specific dermoscopic patterns may lack.1-3 and pigmentation of keratinocytes and the presence of
Reflectance confocal microscopy (RCM) is a noninva atypical melanocytes (pagetoid cells) will be evaluated.
sive imaging technique that produces horizontal images of Keratinocytes are seen as polygonal cells with a dark cen
the skin in a cellular level resolution and in real time. This tral nucleus and bright cytoplasm (honeycombed pattern)
instrument uses a diode laser with a near-infrared wave or as polygonal bright cells fulfilled with melanin (cobble
length of 830 nm that penetrates the skin up to a depth stone pattern), the last being present in more pigmented
of 200–300 μm, which corresponds to the superficial der
lesions. Normal melanocytes are usually not distinguish
mis. The construction of the images is dependent on the
able from pigmented keratinocytes at the basal layer, but
refractive index of the tissue, which changes according to
clustered melanocytes into melanocytic nests are detec
its chemical and molecular structures. In RCM, the refrac
table both at the junction and in the upper dermis in mela
tive structures, such as melanin, keratin, collagen fibers,
nocytic nevi. Atypical melanocytes, usually detectable in
inflammatory cells, and blood cells, appear in white color
with different degrees of intensity on the grayscale, mela melanoma, are large cells (usually at least twice the size
nin and melanosomes being the most important sources of keratinocyte) with a dark central nucleus and a bright
of contrast.4 An excellent applicability of RCM is in the periphery corresponding to high refractive cytoplasm.
field of dermoscopically difficult-to-diagnose melanocytic Shape could be roundish, dendritic, or pleomorphic,
lesions improving the diagnostic accuracy of melanoma usually presenting enlarged thick dendrites or stellate
and reducing the number of excisions of benign mela to bizarre shapes with long dendritic arborization (Figs.
nocytic lesions.5 Classically, lesions are analyzed in three 17.1A to C).
different layers: epidermis, dermal-epidermal junction The RCM aspects in superficial spreading melanoma
(DEJ), and papillary dermis. and Differential Diagnosis with Benign Melanocytic
A B C
Figs. 17.1A to C: Reflectance confocal microscopy of the granular/spinous layer in melanomas presenting different shapes and sizes of atypical
melanocytes infiltrating epidermis in a pagetoid fashion. (A) Presence of roundish pagetoid cells represented by bright large well-defined
polygonal structures with a dark central portion corresponding to the nucleus. (B) Presence of a pagetoid infiltration constituted by dendritic
cells. Cell body is barely visible, whereas all epidermis looks characterized by bright tangled lines corresponding to the dendritic branches of
melanocytes. (C) Pleomorphic pagetoid cells. Some look roundish, others present short-thickened dendrites, stellate, and bizarre shapes.
A B
Figs. 17.2A and B: Reflectance confocal microscopy of a superficial spreading melanoma. (A) Epidermal layer altered by the presence of
numerous pleomorphic cells (arrows). (B) Irregular architecture at dermal–epidermal junction with papillae infiltrated by large aggregates of
atypical cells, and areas of architectural disarrangement (stars).
Lesions. In the last decades, the importance of RCM for resulted characterized by a predominant cellular popu
the diagnosis and classification of melanomas into sub lation, also correlated with patient’s phenotypic aspects
types have been developed.6 Reflectance confocal micros and sun behavior. “Pagetoid melanoma” and “dendritic
copy is able to detect early melanomas when differential cell melanoma,” in fact, corresponded to predominant
diagnosis with benign melanocytic proliferations is still intraepidermal proliferations of malignant cells and thus
difficult upon clinical and dermoscopic examinations. they usually corresponded to superficial spreading mela
Overall, upon RCM the most relevant criteria for mela noma (SSM) type upon histopathologic examination,
noma diagnosis are epidermal disarrangement with pag except for lesions located on the face that were frequently
etoid cells (mainly when those cells are roundish and classified as lentigo maligna and lentigo maligna mela
show a widespread distribution), atypical cells in the DEJ, nomas. On the other hand, “large-clustered melanoma”
altered junctional architecture (resulting in the so-called
usually corresponded to nodular type, and in the case of
nonedged papillae pattern), atypical cells aggregated into
histopathologic classification into SSM, nodular compo
irregular/dishomogeneous nests (Figs. 17.2A and B).5
nent, and vertical growth pattern was always predomi
According to the melanoma progression model, the
nant. “Mixed type” represents a combination of the three
architecture of the junction is progressively disarranged
subtypes, with no predominance of a single pattern.6
by the intraepidermal accumulation of malignant mela
Thus, RCM characterization of SSM can be summa
nocytes in single cells and/or in nests, and subsequent
alterations lead to the microinvasion of the superficial rized into two main categories, joined by the predominant
dermis, followed by nodular proliferation characterized intraepidermal and junctional proliferation.
by vertical growth and deep tumor invasion.7
Upon confocal microscopy, different predominant PAGETOID MELANOMA
aspects can be observed in melanomas. Overall four diffe
rent subtypes of melanomas have been described, namely Pagetoid melanoma is characterized upon RCM by the
“pagetoid melanoma,” “dendritic cell melanoma”, “large presence of numerous roundish and or polygonal cell
clustered melanoma,” and “mixed type.” Each subtype proliferation as single cells, mainly detectable within the
A B
Figs. 17.3A and B: Superficial spreading melanoma, in situ. (A) Upon dermoscopy, atypical network in the periphery and a central dark brown-
to-black structureless pattern. (B) Reflectance confocal microscopy at the level of the epidermis showing numerous predominantly roundish
pagetoid cells, widespread throughout the entire epidermis.
epidermis in a pagetoid fashion (Figs. 17.3A and B) or pattern at the periphery. When atypical cells are pleomor
proliferating at the DEJ, with a tendency to form irregular phic and widespread, and disarrangement of the architec
clusters (Figs. 17.4A and B), sometimes infiltrating the der ture is marked, those lesions can be classified as severely
mal papillae. This uneven cell proliferation is responsible dysplastic nevi upon histopathology, but melanoma
for the disarrangement of the junctional architecture. cannot be ruled out upon RCM, thus excision is recom
From a clinical point of view, pagetoid melanoma usu mended.4,8
ally appears in adults with many nevi and intermittent solar According to melanoma progression, tumor growth
exposure. In the early stage, during the radial growth phase, can switch from radial to vertical phases, with deep inva
atypical melanocytes are still confined to the epidermis. sion of the dermis. At this moment, lesions are clinically
Lesions are usually dark and flat (or slightly elevated), and palpable or present a nodular component, and several
in dermoscopy, atypical reticular and/or globular pattern, dermoscopic patterns characteristic of melanoma are usu
and structureless areas are commonly present. ally visible. Upon RCM, along with numerous roundish to
Due to its clinical-dermoscopic presentation, pagetoid pleomorphic cells into the epidermis, marked alterations
melanoma in its early phase represents a difficult differen of the DEJ and irregular and dishomogeneous clusters of
tial diagnosis with atypical/dysplastic nevus. Reflectance atypical melanocytes, sometimes fulfilling dermal papil
lae, are visible. On histology, remodeling and flattening of
confocal microscopy showed the possibility of improving
the DEJ, and proliferation of malignant melanocytes at the
diagnostic accuracy in these lesions.8 Histopathologic
junction and in the dermis are present.9
grading of dysplasia resulted correlated with RCM cytoar
chitectural disorder. In mild dysplastic nevi, RCM shows
few roundish pagetoid cells at the epidermal layer and at DENDRITIC CELL TYPE MELANOMA
the level of the DEJ, which are characteristically located In this type of melanoma, the following RCM features are
in the center of the lesion. The architecture of the DEJ is present: Epidermal disarray with melanocytic infiltration
slightly irregular with the predominance of elongated mainly composed of dendritic atypical cells (Figs. 17.5A
nests in the center of the lesion and an overall ringed and B) and at the DEJ presence of edged and/or nonedged
A B
Figs. 17.4A and B: Superficial spreading melanoma, Breslow’s thickness 0.3 mm. (A) Upon dermoscopy, the lesion is composed of a dark central
structureless area and dark brown-to-black pseudopods in a starburst distribution. (B) Upon reflectance confocal microscopy lesion is composed,
at the level of the dermal-epidermal junction, by numerous nests of melanocytes.
A B
Figs. 17.5A and B: Superficial spreading melanoma, Breslow’s thickness 0.5 mm. (A) Upon dermoscopy, the lesion is represented predominantly
by a globular pattern with heterogeneous and irregularly distributed globules, and a pinkish area with atypical vessels. (B) Reflectance confocal
microscopy at the level of the granular–spinous layer shows irregular honeycombed pattern with a predominance of dendritic pagetoid cells,
isolated or clustered in small groups (arrows).
papillae, usually characterized by irregular contours and enabling accurate diagnosis of melanoma, and saving over
tangled lines (corresponding to dendrites) in interpapil the 50% of excision of benign lesions. Adequate training
lary spaces. Sometimes some elongated nests are also visi and experience are required for optimal interpretation
ble, usually located at the junction. of confocal images, but this technology should be consi
This subgroup of melanomas frequently occurs in dered as an adjunct for difficult dermoscopic cases.12
sun-damaged skin, in elderly patients, with few melano
cytic nevi. Dendritic cell melanoma diagnosis is sometimes REFERENCES
challenging for clinicians because of the overlapping of
1. Kittler H, Pehamberger H, Wolff K, et al. Diagnostic accu
dermoscopic features with other pigmented macules, such racy of dermoscopy. Lancet Oncol. 2002;3:159-65.
as lentigo simplex, solar lentigo, and/or lichen planus- 2. Argenziano G, Cerroni L, Zalaudek I, et al. Accuracy in mela
like keratosis.10,11 noma detection: a 10-year multicenter survey. J Am Acad
Reflectance confocal microscopy has been shown to Dermatol 2012;67:54-9.
3. Ferrari B, Pupelli G, Farnetani F, et al. Dermoscopic diffi
improve the diagnostic accuracy in these lesions especially
cult lesions: an objective evaluation of reflectance confocal
because of the presence of numerous dendritic cells both microscopy impact for accurate diagnosis. J Eur Acad Der
within upper epidermal layers and junction, compared matol Venereol. 2015;29:1135-40.
with regular honeycombed pattern and ringed/polycyclic 4. Hofmann-Wellenhof R, Pellacani G, Malvehy J, et al. (Eds).
pattern in benign lesions.5 In: Reflectance Confocal Microscopy for Skin Diseases. Ber
lin: Springer-Verlag; 2012.
However, in the diagnostic process, it should also be 5. Pellacani G, Guiterra P, Longo C, et al. The impact of in vivo
considered that abundant dendritic cell proliferation is reflectance confocal microscopy for the diagnostic accu
also accounted in some inflamed lesions, due to Langer racy of melanoma and equivocal melanocytic lesions. J
hans cell proliferation, and in pigmented actinic keratosis, Invest Dermatol. 2007;127:2759-65.
6. Pellacani G, De Pace B, Reggiani C, et al. Distinct mela
as a consequence of melanocytic hyperplasia with large
noma types based on reflectance confocal microscopy. Exp
dendritic melanocytes detectable in the epidermis. Dermatol. 2014;23:414-8.
Thus, in the case of large lesions or lesions located in 7. Clark WH Jr, Elder DE, Van Horn M. The biologic forms of
cosmetically sensitive areas, which are exclusively charac malignant melanoma. Hum Pathol. 1986;17:443-50.
terized by dendritic cell proliferation, a punch biopsy or 8. Pellacani G, Farnetani F, Gonzalez S, et al. In vivo confocal
microscopy for detection and grading of dysplastic nevi: a
shaving, eventually driven on the most suspicious area of
pilot study. J Am Acad Dermatol. 2012;66:e109-21.
the lesion, is recommended. 9. Scope A, Zalaudek I, Ferrara G, et al. Remodeling of the der
During tumor progression, appearance of roundish/ moepidermal junction in superficial spreading melanoma:
polygonal cells and aggregates of atypical melanocytes is insights gained from correlation of dermoscopy, reflec
usually detectable in dendritic cell melanoma, progres tance confocal microscopy, and histopathologic analysis.
Arch Dermatol. 2008;144:1644-9.
sively giving rise to the so-called mixed type. Though, 10. de Carvalho N, Farnetani F, Ciardo S, et al. Reflectance
usually, these tumors present a slow pattern of growth, it confocal microscopy correlates of dermoscopic patterns
is possible for the development of an invasive clone that of facial lesions help to discriminate lentigo maligna from
results in a nodular component, which is characterized by pigmented nonmelanocytic macules. Br J Dermatol. 2015;
173:128-33.
large aggregates of atypical cells upon RCM. Thus, in case
11. de Carvalho N, Guida S, Cesinaro AM, et al. Pigmented
of diagnostic uncertainty in flat lesion, a short- and long- globules in dermoscopy as a clue for lentigo maligna
term follow-up is warranted in order to avoid misdiagnosis. mimicking non-melanocytic skin neoplasm: a lesson from
In conclusion, in vivo RCM is very useful in the field of reflectance confocal microscopy. J Eur Arad Dermatol
difficult-to-diagnose melanocytic lesions and, at the same Venereol. 2015 Feb 17 [Epub ahead of print].
12. Pellacani G, Witkowski A, Cesinaro AM, et al. Cost-benefit
time that, benign lesions are saved from unnecessary exci of reflectance confocal microscopy in the diagnostic perfor
sions, early melanomas are also diagnosed. Its systematic mance of melanoma. J Eur Acad Dermatol Venereol. 2016;
application can also represent a cost-effective strategy, 30(3):413-9.
17.2 THE UTILITY OF CONFOCAL MICROSCOPY

IN THE DIAGNOSIS OF BASAL CELL CARCINOMA
Caterina Longo, Simonetta Piana, Elisa Benatti, Stefania Borsari, Giuseppe Albertini, Aimilios Lallas, Elvira Moscarella
INTRODUCTION of epidermal thickness either under physiologic condition

or in the presence of dysfunctional epidermis.
Reflectance confocal microscopy (RCM) is a relatively Recently, a handheld RCM has been introduced on the
novel imaging tool that enables the identification of cells market (VivaScope 3000). This version is a smaller, flexible
and tissues with nearly histologic resolution. Although device, which is useful in areas that are difficult to access
several noninvasive tools have been explored to test their (e.g. skin folds and ears). Unlike the 1,500 version, it has
potential application in the clinical field, RCM has emerged an on-instrument control for laser power, imaging depth,
as a unique instrument because it can visualize the skin tis and capture, but it does not allow scanning of a large field
sue with a resolution that is comparable with conventional of view, which is needed, for example, in some tumors to
histopathology. It allows a horizontal scanning (en face) of obtain an overview of the architecture. However, it is a
the imaged tissue, with the advantage of exploring a larger promising tool, which can be used for surgical premap
field of view compared with vertical sectioning. ping or when multiple site imaging is requested.
Herein, we report the RCM diagnostic features of dis
tinct basal cell carcinoma (BCC) subtypes and their appli
cation in clinical setting.
BCC CONFOCAL FEATURES
Reflectance confocal microscopy is an excellent tool that
TECHNICAL DETAILS provides an accurate noninvasive diagnosis of BCC. The
RCM features of BCC have been extensively described and
The commercially available confocal microscope (Viva are well-correlated to the histopathological diagnostic cri
Scope 1500, Mavig, GmbH, Munich, Germany) contains a teria of BCC.
probe (the head of the microscope), which is attached to González et al.1 first described the confocal criteria
the skin by using a disposable plastic window, which is, in for the diagnosis of BCC. They include the presence of
turn, taped to a metal ring. A confocal microscope consists elongated monomorphic nuclei, the polarization of these
of a point source of light, a condenser, objective lenses, nuclei along the same axis, a prominent inflammatory
and a point detector. The pinhole collects light emana infiltrate, increased number of vessels, and the pleomor
ting only from the in focus plane. The mechanism of bright phism of the overlying epidermis. However, the presence
contrast in RCM is backscattering. In gray scale confocal of tumor islands and cords is considered the RCM hall
images, structures that appear bright (white) have com mark of the tumor.
ponents with high refractive index compared with their Distinct RCM features are linked mainly to the diffe
surroundings and are similar in size to the wavelength of rent histopathologic subtypes although pigmentation may
light. Backscattering is primarily governed by the refrac also influence the RCM pattern in terms of refractivity.
tive index of the structure compared with the surrounding In fact, pigmented tumors appear highly refractive upon
medium. Highly reflective skin components include mela RCM with basaloid islands that are readily identifiable
nin, collagen, and keratin. The confocal scanning pro whereas hypopigmented or pink lesions result in darker
duces high-resolution black-and-white horizontal images tumor silhouettes, which are challenging to be recog
(0.5 × 0.5 mm) with a lateral resolution of 1.0 mm and an nized. More specifically, in pigmented BCC, the shape
axial resolution of 3–5 mm. A sequence of full-resolution of the tumor islands/cords is clearly outlined by a dark
individual images at a given depth is acquired and stitched contour (clefting)2 in contrast to the brightness of the
together to create a mosaic ranging in size from 2 × 2 mm peripheral palisading of cells. In hypopigmented BCC,
to 8 × 8 mm. Besides the horizontal mosaic, a vertical Viva these structures are called “dark silhouettes,” because of
Stack can be imaged. It consists of single high-resolution their dark footprint-like shadow appearance, which is due
images acquired from the top skin surface up to 200 mm, to the hypopigmented tumor proliferation in a context of
corresponding to the papillary dermis, to obtain an optic bright compact collagen. Additionally, in pigmented BCC,
biopsy. The VivaStack modality is useful for the assessment it is possible to observe the presence of dendritic cells
C B
Figs. 17.6A to C: Superficial basal cell carcinoma. (A) Dermoscopy reveals a pink lesion with a few erosions. (B) Reflectance confocal microscopy
image shows the presence of dark cords (arrows) connected to the epidermis that correspond to (C) the ones observed on histopathology.
inside the tumor islands that correspond to melanocytes and collagen surrounding the islands (Figs. 17.9A to C).
entrapped into the basaloid islands. Along with melano In all BCC subtypes, it is possible to observe an increased
cytes, the pigmentation of BCC upon RCM is linked to the vascularization.
presence of inflammatory infiltrate showing up as bright Apart from the three main histopathologic subtypes,
spots or as ill-defined plump bright cells (corresponding the RCM pattern of fibroepithelioma of Pinkus has been
to melanin-laden melanophages). described. Upon RCM, it is characterized by a “fenestrated
Our research group recently has identified the RCM pattern,”4 consisting of tumor islands or cords with pali
criteria to distinguish three main histological subtypes of sading cells at the periphery that outline hyporefractive
BCC: Superficial, nodular, and infiltrative.3 Namely, super holes corresponding, histopathologically, to the fibrous
ficial BCCs revealed the presence of streaming of the epi stroma (Figs. 17.10A to C).
dermis, cords connected to the epidermis with peripheral
palisading, and collagen surrounding the cords (Figs. 17.6A DIAGNOSTIC ACCURACY OF
to C). On RCM big tumor islands with clefting and periph
eral palisading characterize nodular BCCs (Figs. 17.7A to C).
RCM IN BCC DIAGNOSIS
Pigmented nodular BCCs are typified by the presence of The presence of elongated monomorphic nuclei, the
bright tumor islands and florid inflammatory infiltrate polarization of these nuclei along the same axis, a prom
(Figs. 17.8A to C). Infiltrative BCCs were typified by the inent inflammatory infiltrate, increased number of ves
presence of dark silhouettes with peripheral palisading sels, and the pleomorphism of the overlying epidermis
C B
Figs. 17.7A to C: Nodular basal cell carcinoma (BCC). (A) Dermoscopy shows the presence of multiple in-focus blue gray dots, ovoidal globules,
and arborizing vessels. (B) Reflectance confocal microscopy image reveals the presence of tightly packed hyporeflective basaloid islands
(asterisks) with peripheral clefting (arrows). (C) Histopathology shows the silhouettes of a micronodular BCCs.
C B
Figs. 17.8A to C: Pigmented nodular basal cell carcinoma (BCC). (A) Dermoscopy shows the presence of arborizing vessels. (B) Reflectance
confocal microscopy image reveals the presence of bright and refractive basaloid islands (asterisks) along with clumps of melanophages (arrows).
(C) Histopathology shows the silhouettes of pigmented nodular BCCs.
C B
Figs. 17.9A to C: Infiltrative basal cell carcinoma (BCC). (A) Dermoscopy of this case reveals a whitish plaque with linear-arborizing telangiectasia.
(B) Reflectance confocal microscopy shows dark silhouettes with peripheral palisading and collagen surrounding the islands (red arrows) along
with enlarged vessels (yellow arrow). (C) Histopathology shows the stereotypical pattern of infiltrative BCC.
C B
Figs. 17.10A to C: Fibroepithelioma of Pinkus. (A) Short white lines and erosion typify this tumor upon dermoscopy. (B) A typical fenestrated
pattern with bright basaloid cords (arrows) and fibrous stroma (asterisk) is seen on reflectance confocal microscopy (RCM) image. (C) His
topathology confirms the RCM diagnosis of a fibroepithelioma of Pinkus.
have been reported as RCMs diagnostic features. It has assessment, identification of BCC remnants or recurrence
been demonstrated that the presence of two or more of after treatment, and in Mohs micrographic surgery. In our
these criteria is 100% sensitive for BCC, and the presence experience, a minimal training is required for novices to
of four or more of these criteria guarantees a specificity of recognize BCC structures upon RCM although the diagno
95.7% in the diagnosis of BCC.1 Recently, Guitera et al.5 sis of pink superficial BCCs may result more challenging
described two algorithms to diagnose BCCs and melano compared to pigmented tumors. To conclude, RCM is a
mas using in vivo RCM. A total of 710 consecutive cuta fast imaging tool that can provide a reliable diagnosis for
neous lesions excised to exclude malignancy were imaged those BCCs that are dermoscopically and clinically chal
by RCM. Reflectance confocal microscopy features were lenging.
correlated with pathology diagnosis to develop diagnostic
algorithms. The diagnostic accuracy of the BCC algorithm
REFERENCES
defined on multivariate analysis of the training set (50%)
and tested on the remaining cases had 100% sensitivity 1. González S, Tannous Z. Real-time, in vivo confocal reflec
tance microscopy of basal cell carcinoma. J Am Acad Der
and 88.5% specificity. Positive features were polarized
matol. 2002;47:869-74.
elongated features, telangiectasia, and convoluted vessels, 2. Ulrich M, Roewert-Huber J, González S, et al. Peritumoral
basaloid nodules, and epidermal shadowing correspon clefting in basal cell carcinoma: correlation of in vivo reflec
ding to horizontal clefting. Negative features were nonvisi tance confocal microscopy and routine histology. J Cutan
ble papillae, disarrangement of the epidermal layer, and Pathol. 2011;38:190-5.
3. Longo C, Lallas A, Kyrgidis A, et al. Classifying distinct
cerebriform nests. Other research papers highlighted the
basal cell carcinoma subtype by means of dermatoscopy
role of RCM in providing a fast diagnosis for pink papules and reflectance confocal microscopy. J Am Acad Dermatol.
located on the face and for nodular BCCs that could be in 2014;71:716-24.
differential diagnosis with melanoma. 4. Longo C, Soyer HP, Pepe P, et al. In vivo confocal micro
scopic pattern of fibroepithelioma of pinkus. Arch Derma
tol. 2012;148:556.
CONCLUSION 5. Guitera P, Menzies SW, Longo C, et al. In vivo confocal
microscopy for diagnosis of melanoma and basal cell car
Reflectance confocal microscopy is an accurate tool to cinoma using a two-step method: analysis of 710 consecu
diagnose BCCs in clinical settings. Besides diagnostic tive clinically equivocal cases. J Invest Dermatol. 2012;132:
purposes, RCM found its applications in tumor margin 2386-94.
17.3 THE UTILITY OF CONFOCAL MICROSCOPY IN

THE DIAGNOSIS OF SQUAMOUS CELL CARCINOMA
Elvira Moscarella, Simonetta Piana, Marco Manfredini,
Stefano Gardini, Giuseppe Albertini, Aimilios Lallas, Caterina Longo
INTRODUCTION can be present in well-to-moderately differentiated SCC.

These include amorphous, structureless white-to-yellow
Squamous cell carcinoma (SCC) is the second most com areas, or targetoid-appearing follicular openings consist
mon malignant neoplasia of the skin. It derives from the
ing of an opaque, yellow center surrounded by a white
epithelial squamous cells, and affects more commonly
halo (white circles).2 Poorly differentiated SCC lacks the
fair skinned individuals in areas of chronic sun exposure.1
signs of keratinization and, instead, shows a polymor
Classically, SCC presents as a pink-to-red scaly papule or
phous vascular pattern consisting of small-caliber linear,
plaque, at times ulcerated. Pigmented forms can occur,
hairpin, or glomerular vessels over a reddish background.
although less frequently. Histopathologically, invasive
SCC can be divided into the following three histologic Reflectance Confocal Microscopy
grades, based on the degree of nuclear atypia and keratini
of Squamous Cell Carcinoma
zation found.1 Well-differentiated SCC is characterized by
more normal-appearing nuclei with abundant cytoplasm Confocal features of SCC have been described only in a few
and extracellular keratin pearls. Moderately differentiated reports up to now.3-5 The hallmark of SCC in reflectance
SCC exhibits features intermediate between well-differ confocal microscopy (RCM) examination is the presence
entiated and poorly differentiated lesions. Poorly differ of atypical keratinocytes, forming a disarranged epider
entiated SCC shows a high degree of nuclear atypia with mal pattern. However, because of the presence of marked
frequent mitoses and less keratinization. Squamous cell hyperkeratosis and/or ulceration, RCM is not always suit
carcinoma in situ, also referred to as Bowen’s disease or able for imaging SCC. Both hyperkeratosis and ulceration
intraepithelial carcinoma, is the intraepidermal form, represent a limit for the deep penetration of laser light,
which may ultimately progress to an invasive SCC. so that in many cases RCM is not a feasible imaging tool.
Clinical diagnosis of the tumor is usually readily, even In explorable lesions, however, RCM may represent an
if initial forms may be difficult to distinguish from actinic adjunct tool in the differential diagnosis with other skin
keratoses that are often numerous in the background of tumors and with inflammatory diseases.
severely sun-damaged skin.
Squamous Cell Carcinoma In Situ
DERMOSCOPY (Bowen’s Disease) (Figs. 17.11 to 17.16)
Dermoscopy features of intraepidermal and invasive SCC Starting from the upper layers of the epidermis, superfi
have been recently described.2 The dermoscopic hallmark cial disruption at the level of the stratum corneum with
of nonpigmented intraepidermal carcinoma is the pres single detached keratinocytes can be seen, corresponding
ence of dotted and/or glomerular vessels, usually com to scale crust. Detached keratinocytes appear as bright
bined with white-to-yellow surface scales and a red-yellow polygonal cells with high reflectance. Polygonal nucleated
ish background color.2 This pattern is associated with a 98% cells at the stratum corneum represent parakeratosis. At
diagnostic probability of intraepidermal carcinoma. Pig the level of the spinous and granular layers, the epidermal
mented Bowen’s disease may dermoscopically reveal sev honeycomb is formed by keratinocytes of variable size and
eral pigmented structures, including structureless brown shape, forming an atypical to disarranged honeycombed
to gray areas, brown dots in linear arrangement, thick, pattern. Round nucleated cells can be seen at the level of
pigmented lines, or a combination of these patterns. Inva the spinous layer, corresponding to dyskeratotic keratino
sive SCC can display several different morphologic types cytes.3-5 At the dermal layer, round blood vessels traversing
of vessels, including peripheral hairpin, dotted, and/or through the dermal papillae perpendicular to the skin sur
linear irregular vessels. In addition, signs of keratinization face can be seen.
A B
C D
Figs. 17.11A to D: Confocal features of squamous cell carcinoma. Reflectance confocal microscopy single images 0.5 × 0.5 mm. (A) At the level
of the corneal layer, scale crust appears as brightly reflective amorphous islands (arrows), polygonal nucleated cells represent parakeratosis
(arrowhead). (B) Atypical honeycombed pattern at the level of the spinous granular layer, composed of keratinocytes of different size and shape.
(C) Example of a disarranged epidermal pattern, with the presence of multiple round nucleated cells, corresponding to dyskeratotic cells (arrows).
(D) Small edged papillae at the dermal layer, with round blood vessels traversing through the dermal papillae perpendicular to the skin surface.
A B
Figs. 17.12A and B: In situ squamous cell carcinoma arising on the leg of an 80-year-old man. (A) Clinically, the lesion appeared as an
erythematous plaque with scaly surface. (B) In dermoscopy, multiple white-to-yellow scales, erythematous background and multiple dotted
vessels surrounded by a whitish halo.
C D
Figs. 17.12C and D: (C) Reflectance confocal microscopy image (0.5 × 0.5 mm) at the level of the spinous layer, highlighting the presence of a
disarranged epidermal pattern, with the presence of multiple round nucleated cells, with a targetoid appearance (white arrows) corresponding
to dyskeratotic cells, and small bright cells corresponding to inflammatory cells (red arrows). (D) Histopathologically, the same dyskeratotic cells
show large atypical nuclei with dense chromatin or irregularly round cells with evident nucleoli. Occasional inflammatory cells are evident.
A B
C D
Figs. 17.13A to D: In situ squamous cell carcinoma arising on the upper arm of a 72-year-old woman. (A) In dermoscopy, a structureless white
center and multiple dotted vessels at the periphery of the lesion. Clinical picture is in the inset. (B) Reflectance confocal microscopy single
image (0.5 × 0.5 mm) taken at the level of the corneal layer, showing the presence of brightly reflective amorphous islands corresponding
to hyperkeratosis. (C) On histopathological examination, underneath a hyperparakeratotic layer, neoplastic cells are irregularly round and
sometimes arranged in ill-defined nests. (D) Reflectance confocal microscopy image at the level of the dermal-epidermal layer with round blood
vessels traversing through the dermal papillae perpendicular to the skin surface.
Figs. 17.14A and B: Pigmented squamous cell carcinoma in situ. (A)

Dermoscopy showing a scaly surface, clustered dotted vessels, and
brown dot in a line at the periphery of the lesion. (B) Reflectance confocal
microscopy mosaic image at the level of the superficial epidermis (2.5 ×
1 mm) highlighting the presence of hyperkeratosis, with brightly ref
lective amorphous islands, round, bright aggregates of keratotic material
B corresponding to keratin pearls (arrows).
A B
Figs. 17.15A and B: Pigmented squamous cell carcinoma in situ. (A) Reflectance confocal microscopy image (0.5 × 0.5 mm) of an atypical
honeycombed pattern, with multiple highly reflective dendritic cells (arrows). A milia-like cyst is also detected, appearing as a brightly reflective
onion-shaped structure (white square). (B) Bright aggregates of keratotic material corresponding to keratin pearls (arrow).
Figs. 17.16A and B: Invasive, poorly differentiated squamous cell

carcinoma. (A) In dermoscopy, a prevalence of red color is seen, with
multiple glomerular vessels. (B) Reflectance confocal microscopy mosaic
image (3 × 2.5 mm) at the spinous layer. An extensive area composed
of bright, compact, hyper-reflective particles (white arrows) is visible
on the lesion surface, corresponding to ulceration, and not allowing
the visualization of the deeper layers of the epidermis. A focal area of
B spongiosis is detected (white square).
In pigmented Bowen’s disease, large round and den sometimes present on the lesion surface, represents an
dritic cells can be present in the granular layer, represent additional limit for confocal examination.3-5
ing pigmented keratinocytes or melanocytes. In severely
REFERENCES
sun-damaged skin, Bowen’s disease may arise in an area
1. Yanofsky VR, Mercer SE, Phelps RG. Histopathological vari
of solar lentigo, so that edged papillae can be the seen at ants of cutaneous squamous cell carcinoma: a review. J
the level of the dermal-epidermal junction.3-5 Skin Cancer. 2011;2011:210813.
2. Lallas A, Argenziano G, Zendri E, et al. Update on non-mel
Invasive SCC anoma skin cancer and the value of dermoscopy in its diag
nosis and treatment monitoring. Expert Rev Anticancer
Invasive SCC can display all the features that are visible Ther. 2013;13(5):541-58.
in the in situ form. In addition, in hyperkeratotic lesions, 3. Rishpon A, Kim N, Scope A, et al. Reflectance confocal
keratin pearls can be detected, appearing as round, bright microscopy criteria for squamous cell carcinomas and
actinic keratoses. Arch Dermatol. 2009;145(7):766-72.
aggregates of keratotic material. At the dermal level, nest- 4. Ulrich M, Kanitakis J, González S, et al. Evaluation of Bowen
like structures with surrounding fibrosis can be visual disease by in vivo reflectance confocal microscopy. Br J
ized by RCM. However, the presence of hyperkeratosis Dermatol. 2012;166(2):451-3.
5. Peppelman M, Nguyen KP, Hoogedoorn L, et al. Reflectance
represents a limit in the deep visualization of the tumor,
confocal microscopy: non-invasive distinction between
thus establishing that the level of invasion of the tumor is actinic keratosis and squamous cell carcinoma. J Eur Acad
difficult in the majority of cases. In addition, ulceration, Dermatol Venereol. 2015;29(7):1302-9.
DERMATOSCOPY—
CHAOS AND CLUES 18
Philipp Tschandl, Cliff Rosendahl
“Since pattern analysis takes up a lot of time to master pattern analysis to its full extent,
and to be able to give beginners a method for quickly examining patients, a short method in
algorithmic layout has been formed.
This was initially called “short pattern analysis” but became
generally known as the method “chaos and clues” (C&C).
Three main advantages in comparison to the other algorithms were hoped for:
applicability to melanocytic as well as nonmelanocytic lesions, quick application,
and more easy progression to the “full” pattern analysis method.”
Dermatoscopy—Chaos and Clues 341
BACKGROUND
The application of dermatoscopy to differentiate mela-
noma from nevi has been a focus of this technique since
the late 1980s. Since it seemed complicated for beginners
to identify every possible morphologic feature and inte-
grate them to a diagnosis, other approaches have been
made. Algorithms containing a limited amount of fea-
tures to be evaluated have been constructed and tested.
The most popular and commonly used ones have been
reported in a consensus paper of the International Der-
moscopy Society in 2003: the ABCD rule, Menzies method,
7-point checklist, and the 3-point checklist.1 Almost all of
them calculate a score by evaluating different morpho-
logic features and using a certain cut off classify a lesion as
a melanoma or nevus. This is already one downside as this
takes up time and cannot be performed to many lesions on
a patient. Since many patients at high risk for melanoma Fig. 18.1: Algorithm “chaos and clues.”
are characterized by having many pigmented skin lesions,
these algorithms quickly become less useful in daily prac-
tice. Another major downside of the algorithms is their “Chaos and clues” algorithm has been initially tested
assumption that only melanocytic lesions are being tested against the other commonly known algorithms in regard to
with them. To fulfil this assumption, a “two-step” proce- interobserver agreement and diagnostic accuracy of mela-
dure has been promoted in which the first step involves nocytic lesions and showed comparable results (unpub-
screening for many morphologic features to determine lished data by the authors). After that, its application for
melanocytic status and the second step determines all lesions regardless of melanocytic nature has also been
whether the lesion is a melanoma. This first step not only tested in a consecutive series of patients in a geographic
takes up additional time but is also prone to error in regard area of high ultraviolet exposure.4 A sensitivity of 98.6% for
to diagnostic accuracy, which has been discussed in the basal cell carcinoma, 86.5% for squamous cell carcinoma,
literature.2 and 79.3% for melanoma was found, with an overall sensi-
In sum, the mentioned algorithms take up a lot of tivity to find any kind of malignancy of 90.6% paired with a
time, and are only applicable for melanocytic lesions and specificity of 62.7%. The highest rate of false-positive cases
are prone to be erroneous due to their necessity for a two- was due to lichen planus like keratoses, by nature often
step procedure. For this reasons, the need for a differ- being chaotic and difficult to differentiate from malignant
ent approach emerged. Since the revival of dermoscopic lesions morphologically.
research in the late 1980s, pattern analysis was regarded
as the very basis of this technique, and has been refined CHAOS AND CLUES—THE METHOD
by modification to more objective terms by Harald Kittler.3 The algorithm uses the basic terminology of modified
Since it takes up a lot of time to master pattern analysis to pattern analysis; for details on basic elements and their
its full extent, and to be able to give beginners a method arrangement, refer to the respective chapter of this book
for quickly examining patients, a short method in algo- (see Chapter 12).
rithmic layout has been formed. This was initially called The chaos and clues algorithm consists of two ques-
“short pattern analysis” but became generally known as tions (Algorithm, Fig. 18.1), the first being “Is chaos
the method “chaos and clues” (C&C) Three main advan- present in the lesion”?
tages in comparison to the other algorithms were hoped
for: applicability to melanocytic as well as nonmelanocytic Chaos
lesions, quick application, and more easy progression to The first step in the algorithm is to scan a lesion for asym-
the “full” pattern analysis method. metry in color or structure, in short: “chaos.” This step is
A B
C D
Figs. 18.2A to D: Four lesions on the same patient. Lesions A to C are symmetrical; lesion D is asymmetrical (Chaos) and shows pseudopods as a
clue. Lesion D was diagnosed as an in situ melanoma.
designed to be intuitive and quick to enable the physician chaotic” if the inner dermoscopic structures are evenly
to evaluate many lesions and quickly skip those which are and symmetrically distributed. Last, one should be cautious
unequivocally benign. Though seeming very straightfor- in some special situations: nodular, especially fast grow-
ward, the exact evaluation of “chaos” needs some explana- ing or changing lesions, should always be biopsied
tion and training of the eye. The reason for this is that one if no unequivocal benign diagnosis can be made. Flat
should not expect perfect architectural symmetry, as this pigmented lesions on the face with gray color are always
suspicious for being malignant, even if symmetric. Acral
is extremely rare in biologic systems. A helpful approach
lesions with a symmetric pattern of parallel lines on the
to train the eye on what is “chaotic” and what is not is to
ridges are always suspicious for being an acral melanoma.
compare many lesions of the same patient, which usually If no “chaos” is present, the lesion can be omitted and
show similar patterns. This—also known as the “compar- the examiner can move on to the next lesion.
ative approach”—is often able to distinguish the “chaotic” If “chaos” is present, the examining physician evalu-
lesion on a patient from the regular ones (Figs. 18.2A to D). ated the lesion further by moving on to the second step/
Another important point is not to confuse structure with question of the algorithm: “Is there a clue to malignancy
form: a lesion with an asymmetric outline can still be “not present in the lesion?”
Dermatoscopy—Chaos and Clues 343
A B
C D
E F
Figs. 18.3A to F: Different dermoscopic clues suggesting malignancy. Lesions A to H depict melanomas except lesion C, which is a basal cell
carcinoma: (A) Eccentric structureless area. (B) Focal thick lines reticular. (C) Gray dots. (D) Black clods peripheral. (E) Lines radial/pseudopods
segmental. (F) White lines.
G H
Figs. 18.3G and H: (G) Polymorphous vessels. (H) Lines parallel on the ridges.
Clues If they are present on the ridges (parallel ridge pat-

The second step of the algorithm screens the lesion for tern) this is a clue to malignancy. Though this clue is
the presence of at least one of the further described “clues exclusive to acral skin, all other clues can also appear
to malignancy” (Figs. 18.3A to H). If one of those clues is on this anatomic site. If longitudinal/parallel pigmen-
present, this suggests the presence of a malignant lesion tation on a nail has an asymmetric distribution of color
and mandates (excision) biopsy of the lesion: or structure, this is a clue to malignancy.
•• Eccentric structureless area (Fig. 18.3A): Area at the
edge of a lesion without any discernible structure that REFINEMENTS
can hold any color except skin color
Though not being included in the initial description of the
•• Thick lines reticular (Fig. 18.3B): Reticular or branched
presented algorithm, it has been proposed to add one layer
lines where lines are thicker than the nonpigmented
in the beginning to further quicken the screening of patients
holes in between
in daily practice. Before assessing the lesion for “Clues,”
•• Gray or blue structures (Fig. 18.3C): Any known struc-
morphologically unequivocal seborrheic keratoses should
ture (dots, clods, or circles) with blue or gray color
be omitted because of their abundance and ability to being
•• Black dots or clods, peripheral (Fig. 18.3D): Dots or clods
easily diagnosed. This additional step is potentially increas-
at the border of the lesion, distributed asymmetrically
ing performance and speed of the examination dramati-
•• Lines radial or pseudopods, segmental (Fig. 18.3E):
cally with growing experience of the physician.
Lines or pseudopods (line with a clod at one end)
directing outside the lesion or to a common base;
those lines/pseudopods do not encompass the whole REFERENCES
perimeter but are arranged segmentally. 1. Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of
•• White lines (Fig. 18.3F): White lines, often perpendicu- pigmented skin lesions: results of a consensus meeting via
lar to each other. The color “white” is defined as being the Internet. J Am Acad Dermatol. 2003;48(5): 679-93.
2. Tschandl P, Rosendahl C, Kittler H. Accuracy of the first step
brighter than the surrounding skin. of the dermoscopic 2-step algorithm for pigmented skin
•• Polymorphous vessels (Fig. 18.3G): Vessels can appear lesions. Dermatol Pract Concept. 2012;2(3):203a08.
in different ways dermoscopically, as dots, clods, lines, 3. Kittler H. Dermatoscopy: Introduction of a new algo-
looped, curved, serpentine, helical, or coiled. If in rithmic method based on pattern analysis for diagnosis
a single lesion, at least two of these appearances are of pigmented skin lesions. Dermatopathol Pract Conc.
2007;13(1).
combined, this is called “polymorphous.”.
4. Rosendahl C, Tschandl P, Cameron A, et al. Diagnostic
•• Lines parallel, on ridges (acral), or asymmetric (nails) accuracy of dermatoscopy for melanocytic and nonmela-
(Fig. 18.3H): On acral skin parallel lines can appear in nocytic pigmented lesions. J Am Acad Dermatol. 2011;64(6):
the furrows, on the ridges, or perpendicular to those. 1068-73.
INDEX
Page numbers followed by f refer to figure and t refer to table
A Basaloid cell strings 54f Clark’s nevus 124, 207, 211, 213,
Big ovoid nests 17 271, 275f
ABCD rule 189, 250, 251f, 251t, 341
Biopsy 237 Clear cell acanthoma 28f, 99, 99f
Acanthotic rete ridges, basal
Blood spots 89 Clod vessels 25f
hyperpig mentation of 277f
Blue cellular nevus 152f Cobblestone pattern 127f, 250
Acquired melanocytic nevi 135, 136f-138f
Blue globular pattern 42, 48f Collarette scale 296
Acral melanoma 184, 187f, 188f, 244f
Blue nevus 6, 17f, 35f, 152, 155, 155f, Collision tumors 207, 211f, 213
Acral nevus 17f, 35f, 185f
207, 213 Comma-like vessels 26f, 29
Actinic keratosis 83, 84f-86f, 207, 213,
Blue-black pigmented lesion 6 Congenital
224f, 225f
Blue-gray globules 36f melanocytic nevus 124, 135
Age-related nevus patterns 122f
multiple 61, 68 medium 132f
Aggregated globules 16, 113, 114f, 115f
Alopecia areata 301, 302f Blue-gray ovoid nests, large 61, 68 nevus 134f, 219f, 234, 235f, 275f, 277f
Amelanotic melanoma 189 Blue-gray pigmentation 18f, 58, 65, 68 Constitutional pathway 120, 121
American College of Rheumatology 314 Blue-red lacunes 17 Crown curved linear vessels 27
Amorphous structures 288f Blue-white veil 4f, 42, 116, 118f, 166, 169f, Crown vessels 27f, 29
Ancylostoma braziliense 290 250, 252 Curvilinear vessels 27
Androgenetic alopecia 301, 301f Bowen’s disease 88, 89, 333 Cylindroma 100, 100f
Angiogenesis 314 Bowenoid papulosis 109, 109f
Angiokeratoma 72, 74, 74f, 75f Brain-like D
Angioma 17t, 19f, 25f, 28, 72, 72f, 73f, appearance 41, 42f
Delicate peripheral pigment network 78
218f, 238, 240f pattern 18f
Dendritic cell
Arborizing telangiectasias 297f Brown globules 15f, 16f, 35f
melanoma 324
Arborizing vessels 18f, 26f, 28, 29, 36f, 68 Brown-black globules, multiple 69
type melanoma 325
Asymmetric blue nevus 152f Dermatobia hominis maggots 290, 290f
Asymmetric pigmentation 250 C Dermatofibroma 77, 77f-80f, 207, 209f,
Atypical blue nevus 212f Capillaroscopic patterns 315t 213, 217, 218f, 269, 271f
Atypical globular pattern 162 Capillaroscopic scleroderma Dermatomyositis 309, 315, 316, 316f
Atypical mole syndrome 262f pattern 315f, 316f Dermatoscopy 339
Atypical pigment network 4f, 162, 252 Capillaroscopy application of 341
Atypical reticular pattern 162 qualitative 311 Dermoepidermal junction 114f
Atypical Spitz quantitative 311 Dermoscope 309f
nevus 212f Capillary comb 309 Dermoscopic atypia, signs of 258f
tumor 149, 150f Dermoscopic pattern 77, 237
Capillary density 313
Atypical vascular pattern 252
Capillary dilation 311, 312f Dermoscopy 24t
Capillary erythrocyte extravasation 313 digital 257, 262
B Capillary loss 314 images, sequential digital 255
Basal cell carcinoma 15f, 17t, 18f, 26f, 34f, Capillary neoangiogenesis 313 Diabetes 317
36f, 54, 54f-65f, 68t, 69f, 69t, 70f, Capillary thrombosis 312 mellitus 309
71f, 101, 207, 207f, 211, 213, 217, Central hyperkeratosis 88f, 89, 89f Diffuse hairpin vessels 27, 28f
218f, 219, 219f, 277f, 279f, 328, 343f Central mixed pattern 127f Discoid lupus 296
concentric structures 66f-68f Central white patch 78 erythematosus 304, 305f
multiple blue 65f, 66f Cicatricial alopecia 302 lesions 297f
small multiple erosions 68f Cladosporium werneckii 288 Dynamic polarized dermoscopy 82
Index.indd 345 10-04-2017 16:44:10

Dysplasia Halo melanoma 189 Lentiginous melanocytic

mild 141f Hemangioma 18f, 27f, 34f, 36f, 217, 277f proliferation 121f
severe 142f, 143f dermoscopic image of 6f Lentigo 217
Dysplastic nevi 140 Hematomas 207, 213 Lentigo maligna 83, 177, 178f-181f, 185f,
Hemorrhagic spots 242 186f, 226f
E Homogeneous melanoma 177, 181f, 223
blue coloration 6 progression model 177, 178f
Eccrine poroma 96, 96f-98f, 207, 210f Lentigo solaris 16
blue pigmentation 16, 17f, 35f, 113, 115f
Eczemas 296 Lesions
pattern 130f, 135, 146, 227, 233f, 250
Endothelial markers, active 317 assessment of multiple 200
Human papillomavirus 287
Entomodermoscopy 285 combined 215, 217
Hyperkeratosis 88f, 94f
Erythema 316f Lice 290
Hyperkeratotic follicles 86
Exophiala phaeoannellomyces 288 Lichen planopilaris 302, 303, 303f
Hyperpigmented central mixed
Exophiala werneckii 288 Lichen planus 108, 108f, 225, 275, 279f,
pattern 128f
Hyperpigmented Spitz nevus 147f 295, 296f
F Hypertension 309 like keratosis 271f, 225f
Face 223 Hypertrichosis 131, 134f Lichen sclerosus 296
Fact congenital nevus 278f Hyphal pattern 238 Lichenoid chronic cheilitis 240f
Fat fingers 42 Hypomelanotic melanoma 23f, 27, 29f, 193f Light reflection scheme 15f
Fibrillar pattern 188, 227, 232f, 233 dermoscopic classification of 189 Lineal network fragments 133f
Fibrosis 117f in situ 190f-193f Linear vessels 25
Fibrous stroma 331f Hypopigmented central mixed Little red riding hood sign 203f, 204f
Fibrovascular stroma 54f pattern 128f Longitudinal melanonychia 207, 213, 213f
Fingerprint-like Hypopigmented melanoma 189, 281f Lupus vulgaris 291
pattern 238, 238f
structures 16, 49, 223 I M
Fish scale-like pattern 213f, 238, 238f, 239f Malar erythema 316f
In situ melanoma 279f
Fissures and ridges 16, 41 Malignant tissue, chaotic behavior of 275f
In situ squamous cell carcinoma 334f, 335f
Flat warts 288f Melanic pigment 19f
Infiltrative basal cell carcinoma 331f
Flower-like appearance 98f Melanocytes, upward migration of 120
Ink-spot lentigo 49, 51f, 207, 208f, 213
Follicular openings 276f Melanocytic category 275
Intradermal nevus 26f, 28f
asymmetric pigmentation of 52f, 53f Melanocytic lesion 3f, 4f, 16t, 33f, 37t, 65,
Irregular lineal vessels 29, 189
brown pigmentation of 52f, 53f 111, 113, 116
Irregular pigmentation 166, 252
pigmentation of 85f, 86f, 224 benign 257, 323
Irregular vascular pattern 166, 171f
Follicular pseudocysts 35f rule out 34f
Irritative dermatitis 291
Folliculitis decalvans 304, 304f Melanocytic maculae 207
Ixodes ricinus 291
Frontal fibrosing alopecia 303, 304f Melanocytic melanoma simulators 207
Fungal infections 288 Melanocytic nevus 237f
Furrow parallel pattern 17f
J
Melanoma 4f, 7f, 8f, 11f, 17f, 19f, 25f, 26f,
Furuncular myiasis 290, 290f Jelly sign 16, 49, 50, 223 37f, 162, 217, 238, 241f, 249f, 257,
Junction nevus 34f, 217f, 218f 258f, 259f, 261f, 262f, 272, 273f,
G 276f, 279f, 281f, 323
Genital melanotic macule 237f-238f
K in situ 8f, 164f, 170f, 194f
Genitalia 10f Kaposi’s sarcoma 271f metastasis 153, 153f
Giant congenital melanocytic nevus 132f Keratinocytic categories, simulators 205, 213t
Globular pattern 5f, 124, 127f, 146, 227, benign 273, 274 Melanosis 117f
233f, 250 Keratoacanthoma 27f, 28f, 88, 88f, 89f Melanotic labial macule 213f
Melanotic maculae 213
Globules 251 Keratosis 279f
Menzies method 341
multiple 17 Keratotic central mass 28f
Microhemorrhages 312, 313f, 314
Glomerular vessels 9f, 26f
Micro-Hutchinson sign 245
Gottron papules 316f L Milia-like cysts 16, 41, 43f, 44f, 131
Granuloma annulare 298f
Labial melanotic macule 237f-240f Mixed connective tissue disease 309, 317,
Lacunae 6f, 29, 72 317f
H Larva migrans 290, 291f Molluscum contagiosum 103, 103f, 287,
Hair follicle openings, multiple 304f Leishmania 291 288f
Hairpin vessels 26f, 27, 28f, 29, 43, 43f, 189 infantum 291 Moth-eaten border 49, 223
multiple 4f Leishmaniosis 291 Mucosa 237
Index.indd 346 10-04-2017 16:44:11

Index 347
Multicomponent pattern 131f, 135, 162, Peripheral telangiectatic vessels 288f Rheumatoid arthritis 317, 317f
241f, 250 Peripheral vessels 88f Rhomboidal structures 87, 87f, 180f, 181f,
Mycological culture 302 Phaeoannellomyces werneckii 288 182, 226
Phthirus pubis 290 Ring-like pattern 238, 240f
N Pigment network 4f, 16, 16f, 65, 69, 113, Rosette-like structures 84f, 85f, 224f
113f, 114f, 250, 251
Nailfold capillaroscopy 309
Necrobiosis lipoidica 297f
Pigment traces 189 S
Pigmentation, drug-induced 245f
Negative pigment network 4f, 162, 250 Sarcoidosis 298f
Pigmented actinic keratosis 83f, 84, 85f-
Neoangiogenesis 313, 313f 86f, 208f, 224f, 268, 271f Sarcoptes scabiei 289
Neoformed vessels 313 Pigmented basal cell carcinoma 54f, 271f, Scabies 289
Nevogénesis 120 273 Scleroderma 315
constitutional pathway of 120f, 121f, simulating melanoma 68f pattern 312, 314
122 Pigmented Bowen’s disease 91, 91f-94f active 314f
dual concept of 121t Pigmented lesion 3f, 4f, 10f Sclerotic blue nevus 156f
two pathways of 120 dermoscopy of 177 Sebaceous hyperplasia 27f, 104, 104f,
Nevus 7f, 18f, 217, 218f, 243f, 244f Pigmented lichen planus 240 105f, 217, 219f
atypical 140, 140f-143f, 207 Pigmented nodular basal cell Seborrheic keratosis 3f, 16, 16t, 18f, 19f,
combined 152, 156f, 207, 212f, 213 carcinoma 330f 26f, 28f, 33f, 35f, 41f-48f, 49, 207,
compound 6, 15f, 35f Pigmented seborrheic keratosis 209f 211f, 213, 217, 217f-220f, 225, 225f,
multiple 196, 197f Pigmented skin lesion 267f 271f, 277f, 278f, 282f
excisions of typical 10f Pigmented Spitz nevus 147f, 148f Senile purpura 220f
recurrent 158, 159f, 160f, 207, 211f, 213 Pigmented squamous cell Sentinel lymph node 150
Nodular basal cell carcinoma 330f carcinoma 267f, 271f Shiny white structures 250
Nodular melanoma 123, 173, 174f, 175f in situ 280f, 336f Signature nevus 10, 200
Nonarborizing vessels 65, 69 Pityriasis rosea 295, 296 Solar
Noncicatricial alopecia 301 Plaque psoriasis 295f keratoses 83
Noninfectious granulomas 296 Polarized light 24 lentigo 18f, 49, 49f-53f, 83f, 267f, 217,
Nonmelanocytic lesion 3f, 4f, 96 dermatoscope 23f 223, 224, 275f, 276f
Nonmelanocytic melanoma Polygons 273, 283 Spider spine 291
simulators 207 Polymorphic vascular pattern 96 Spitz nevus 5f, 35f, 124, 145, 147f-149f, 275
Nonpigmented actinic keratosis 84 Polymorphous vessels 273, 283, 344f Spitzoid melanoma 146f
Nonpigmented Bowen’s disease 89f-91f Porokeratosis 106, 106f Spitz-Reed nevus 207, 213
Nonpolarized light 24 Predictive value 312 Splinter hemorrhages 242, 242f, 243f
dermatoscope 23f Predominant nevus pattern 10, 200 Squamous cell carcinoma 9f, 25f-27f, 83,
Normal capillaroscopy 309, 310f Pseudocysts, multiple 3f, 18f 88, 91f, 92, 94f, 207, 208f, 213, 217,
Pseudofollicular openings 3f, 41, 43f 333, 334f, 336f
O Pseudoparallel-ridge pattern 234, 235f, 236f in situ 89f, 90f, 91, 91f-94f, 279f, 333
Pseudopod 69, 252, 267 Stable melanocytic lesions 258f
Onychomycosis 289, 289f pattern of 275 Starburst 15
segmental 273, 282, 344 pattern 146, 162, 250
P Pseudo-red appearance 97f Stratum spinosum/granulosum 323
Psoriasis 24f, 295, 317 Strawberry pattern 84f-86f, 223, 224f
Pagetoid cells 323
Pyogenic granuloma 107, 107f, 207, Subpapillary plexus 309, 310f, 315
Pagetoid melanoma 324
210f, 213 visualization 312f, 316, 317f
Papillomatosis 109f
Subungual hematoma 7f, 210f
Parallel furrow pattern 7f, 116f, 227,
227f-231f R Subungual hemorrhage 242f, 243f
Superficial basal cell carcinoma 83f, 329f
Parallel lineal pattern 243f Radial peripheral distribution 28f Superficial spreading melanoma 162,
Parallel ridge pattern 184 Radial vessels 27f 164-168f, 169, 169f, 170f, 172f, 194f,
Parasitic infestations 289 Raynaud’s phenomenon 309, 315f, 316f 195f, 250f, 323, 324, 324f, 326f
Patched reticular pattern 126f Red rhomboidal structures 182f Systemic lupus erythematosus 309, 315
Pediculus humanis capitis 290 Reflectance confocal microscopy 120, disease activity index 316
Perifollicular pigmentary changes 131 321, 323, 328, 332, 333 Systemic sclerosis 309, 315, 315f
Perifollicular whitish halo 297f Regression 42, 116, 252
Peripheral black dots and clods 272 structures 166, 250, 252
Peripheral hairpin vessels 89f
T
Regular parallel longitudinal lines 243
Peripheral mixed pattern 129f Reticular pattern 4, 124, 125f, 146, 227, Targetoid hemosiderotic hemangioma 75
Peripheral streaks pattern 162 233f, 234f, 250 Telangiectasia, narrow short 65, 68
Index.indd 347 10-04-2017 16:44:11

Telangiectasic vessels 297f U Viral

Thrombosed angioma 74f infections 287
Thrombosed hemangioma 207, 209f, 213 Ugly duckling sign 10, 200, 203f wart 287f
Tinea capitis 288, 302, 302f Ulcerations 36f, 63, 68
Tinea nigra 288, 288f Ulcers, digital 315, 315f
Ultraviolet-enhanced
W
Total dermoscopy score 251f, 252
Transition pattern 234, 234f, 235 trichoscopy 302 Warts 287
Traumatized angioma 74f Urticaria 296, 297f White shiny linear streaks 78, 81f
Trichoepithelioma 101, 101f Whitish striae 296f
Trichoscopy 299, 301 V
Trichotillomania 301, 302f Z
Tunga penetrans 290 Verrucae vulgaris 102, 102f
Tungiasis 290 Videocapillaroscopy 309 Zigzag hairs 302f
Index.indd 348 10-04-2017 16:44:11

Cabo H. Color Atlas of Dermoscopy 2018

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Color Atlas of

Horacio Antonio Cabo MD PhD

The Health Sciences Publisher

Color Atlas of Dermoscopy

Horacio A Cabo MD PhD Alessio Gambardella MD Elvira Moscarella MD

Giovanni Pellacani MD Lidia Rudnicka MD PhD Santa Fe, Argentina

5.8.8 Porokeratosis 106

9.1 Face 223

Fig. 1.21: Subungual hematoma. Fig. 1.22: Subungual hematoma.

Table 1.2: Comparative dermoscopic approach.

•• Dermoscopy has been shown to improve the diagnosis

Fig. 2.5: Pigment network. Fig. 2.6: Brown globules.

SUGGESTED READING Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-

”In order to follow a diagnostic algorithm for dermoscopic

Fig. 3.4: Hypomelanotic melanoma image captured with a polarized

Fig. 3.21: Crown vessels—sebaceous hyperplasia. Fig. 3.22: Radial vessels—keratoacanthoma.

Since the morphology of the vessels can be the same

Table 3.2: Correlations between vessels morphology and diseases.

Table 4.2: Diagnostic methods for melanocytic lesions.

Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat­

5.1 SEBORRHEIC KERATOSIS

Vascular Pattern (Figs. 5.7 to 5.12) ADDITIONAL OBSERVATION CRITERIA

Fig. 5.23: Seborrheic keratosis—polarized light.

Polarized Light Versus Nonpolarized Light

SUGGESTED READING Marghoob A, Braun R, Kopf A. Atlas of Dermoscopy. London:

5.2 SOLAR LENTIGO

It generally appears in highly photodamaged skin, as

SUGGESTED READING Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-

5.3 BASAL CELL CARCINOMA

DERMOSCOPIC CRITERIA FOR BASAL

Fig. 5.72: Basal cell carcinoma. Arborizing vessels.

Histologically they are the result of melanin pigment

Nonclassic Criteria Criteria Similar to those

Fig. 5.103: Basal cell carcinoma concentric structures (arrows).

Fig. 5.105: Basal cell carcinoma concentric structures (arrow).

Table 5.1: Basal cell carcinoma.

Fig. 5.109: Clinical and dermoscopic images of a pigmented basal cell

Table 5.2: Basal cell carcinoma.

Fig. 5.110: Basal cell carcinoma: multiple dots/brown-black globules

•• Multiple blue-gray dots (pepper-like) (Fig. 5.112)

Cabo H. Dermatoscopia, 2nd edition. Buenos Aires, Argentina:

5.4 ANGIOMAS AND ANGIOKERATOMAS

ANGIOMAS to dilated blood vessels in the dermis. Their metaphoric

Fig. 5.129: Angiokeratoma. Fig. 5.130: Angiokeratoma.

Fig. 5.131: Angiokeratoma. Fig. 5.132: Angiokeratoma.

Fig. 5.133: Angiokeratoma. Fig. 5.134: Targetoid hemosiderotic hemangioma.

•• Absence of pigmented structures (pigmented net­

SUGGESTED READING Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea-

Fig. 5.160: White shiny linear streaks or crystal structures (arrow).

5.6 ACTINIC KERATOSES

DERMOSCOPIC CRITERIA four-leafed clover, located mainly within the follicular

Cuellar F, Vilalta A, Puig S, et al. New dermoscopic pattern in

5.7 KERATOACANTHOMA, BOWEN’S DISEASE AND SQUAMOUS CELL CARCINOMA

KERATOACANTHOMA presence of these dermoscopic characteristics makes it

Dermoscopic Criteria In most cases, its clinical manifestation is a well-

Squamous Cell Carcinoma In Situ—Pigmented

areas, as well as a combination of brown or gray dots. The •• Brown color

Linear arrangement of brown or gray dots Squamous Cell Carcinoma

SUGGESTED READING Menzies S, Crotty K, Ingvar C, et al. An Atlas of Surface Micros-

5.8 OTHER NONMELANOCYTIC LESIONS

Kittler H. Dermatoscopy. An Algorithmic Method Based on Pat

•• Absence of pigmented structures (pigmented net

SUGGESTED READING Malvhey J, Puig S. Principles of Dermoscopy. Barcelona: Crea