Dermoscopy of pigmented skin lesions - Dermatology

CLINICAL REVIEW 

Dermoscopy of pigmented skin lesions 

Ralph Peter Braun, MD, a Harold S. Rabinovitz, MD, b Margaret Oliviero, ARNP, MSN, b 

Alfred W. Kopf, MD, c and Jean-Hilaire Saurat, MD a 

Geneva,Switzerland;Miami,Florida;andNewYork,NewYork 

Dermoscopy is an in vivo method for the early diagnosis of malignant melanoma and the differential 

diagnosis of pigmented lesions of the skin. It has been shown to increase diagnostic accuracy over clinical 

visual inspection in the hands of experienced physicians. This article is a review of the principles of 

dermoscopy as well as recent technological developments. ( J Am Acad Dermatol 2005;52:109-21.) 

In the last two decades a rising incidence of 

malignant melanoma has been observed. 1-7 

Because of a lack of adequate therapies for 

metastatic melanoma, the best treatment currently 

is still early diagnosis and prompt surgical excision of 

the primary cancer. 5,7 Dermoscopy (also known as 

epiluminescence microscopy, dermatoscopy, and 

amplified surface microscopy) is an in vivo method, 

that has been reported to be a useful tool for the early 

recognition of malignant melanoma. 8-11 The performance 

of dermoscopy has been investigated by 

many authors. Its use increases diagnostic accuracy 

between 5% and 30% over clinical visual inspection, 

depending on the type of skin lesion and experience 

of the physician. 12-16 This was confirmed by recent 

evidence-based publications and based on a metaanalysis 

of the literature. 17,18 This article is a review of 

the principles of dermoscopy as well as recent 

technological developments. 

From the Pigmented Skin Lesion Unit, Department of Dermatology, 

University Hospital Geneva a ; Skin and Cancer Associates, 

Plantation, Fla, and Department of Dermatology, University of 

Miami School of Medicine b ; and The Ronald O. Perelman 

Department of Dermatology, New York University School of 

Medicine. c 

Funding sources: The work of Dr Braun has been supported by the 

Swiss Cancer League. Dr Kopf has the following funding 

sources: The Ronald O. Perelman Department of Dermatology, 

New York University School of Medicine, Joseph H. Hazen 

Foundation, Mary and Emanuel Rosenthal Foundation, Kaplan 

Comprehensive Cancer Center (Cancer Center Support Core 

Grant No. 5P30-CA-16087), Blair O. Rogers Medical Research 

Fund, The Rahr Family Foundation, and Stravros S. Niarchos 

Foundation Fund of the Skin Cancer Foundation. 

Conflict of interest: None. 

Accepted for publication November 9, 2001. 

Reprint requests: R. P. Braun, MD, Department of Dermatology, 

University Hospital Geneva, 24, rue Micheli-du-Crest, CH— 

1211Geneva 14, Switzerland. E-mail: braun@melanoma.ch. 

0190-9622/$30.00 

ª 2005 by the American Academy of Dermatology, Inc. 

doi:10.1016/j.jaad.2001.11.001 

HISTORY OF DERMOSCOPY 

Skin surface microscopy started in 1663 with 

Kolhaus who investigated the small vessels in the 

nailfold with the help of a microscope. 11,19 In 1878, 

Abbe described the use of immersion oil in light 

microscopy 20 and this principle was transferred to 

skin surface microscopy by the German dermatologist, 

Unna, in 1893. 21 He introduced the term 

‘‘diascopy’’ and described the use of immersion oil 

and a glass spatula for the interpretation of lichen 

planus and for the evaluation of the infiltrate in lupus 

erythematosus. The term ‘‘dermatoscopy’’ was introduced 

in 1920 by the German dermatologist 

Johann Saphier who published a series of communications 

using a new diagnostic tool resembling 

a binocular microscope with a built-in light source 

for the examination of the skin. 22-25 He used this new 

tool in various indications and did some interesting 

morphological observations on anatomical structures 

of the skin which indicated the high performance 

of his equipment. Skin surface microscopy 

was further developed in the United States by 

Goldman in the 1950s. He published a series of 

interesting articles on new devices on what he called 

‘‘Dermoscopy.’’ 26-29 He was the first dermatologist to 

use this new technique for the evaluation of pigmented 

skin lesions. In 1971, Rona MacKie 30 clearly 

identified, for the first time, the advantage of surface 

microscopy for the improvement of preoperative 

diagnosis of pigmented skin lesions and for the 

differential diagnosis of benign versus malignant 

lesions. These investigations were continued mainly 

in Europe by several Austrian and German groups. 

The first Consensus Conference on Skin Surface 

Microscopy was held in 1989 in Hamburg 31 and the 

Consensus Netmeeting on Dermoscopy, which was 

held in 2001 in Rome 32 (http://www.dermoscopy. 

org), was the first international meeting of its 

kind. Today dermoscopy has become a routine 

technique in Europe and is gaining acceptance in 

other countries. 

109

110 Braun et al 

Table I. Vascular architecture of pigmented skin lesions according to Kreusch and Koch 57 

PHYSICAL ASPECTS 

Light is either reflected, dispersed, or absorbed by 

the stratum corneum because of its refraction index 

and its optical density, which is different from air. 33 

Thus, deeper underlying structures cannot be adequately 

visualized. However, when various immersion 

liquids are used, they render the skin surface 

translucent and reduce the reflection, so that underlying 

structures are readily visible. The application 

of a glass plate flattens the skin surface and 

provides an even surface. Optical magnification is 

used for examination. Taken together, these optical 

means allow the visualization of certain epidermal, 

dermo-epidermal, and dermal structures. 

MATERIAL FOR DERMOSCOPY 

Dermoscopy requires optical magnification and 

liquid immersion. This can be performed with very 

simple, inexpensive equipment. 34,35 Specially designed 

handheld devices with 10 to 20 times magnification 

are commercially available (Dermatoscope 

[Heine AG]; DermoGenius Basic [Rodenstock 

Präzisionsoptik]; Episcope [Welch-Allyn]; DermLite 

[3Gen, LLC]). Photographic documentation can be 

performed with a dermoscopic attachment to a standard 

camera (Dermaphot, Heine, AG) which can be 

used also with some digital cameras. Most recently, 

digital cameras have been designed that are attached 

to computers. This allows easy storage, retrieval, and 

follow-up of pigmented skin lesions. For dermatologists 

with less experience in dermoscopy, some of 

the systems may offer the possibility of computerassisted 

diagnosis for malignant melanoma or for 

consulting an expert through telemedicine. 

Morphological aspect Type of pathology 

Tree-like vessels Thick, arborizing vessels, superficial Pigmented BCC of any type (discrete in 

superficial BCCs) 

Corona vessels ‘‘Surround’’ the tumor 

Thinner than tree-like vessels 

Less curved than tree-like vessels 

Sebaceous gland hyperplasia 

Comma-shaped vessels Short, strong, curved, 

Located on the tumor 

Short distance, parallel to skin surface 

Dermal nevi 

Point vessels Short capillary loops Thin malignant melanomas 

Dense packed red points Epithelial tumors such as actinic keratosis, 

Not in the holes of the pigment network Bowen’s disease, etc (short vertical height) 

Hairpin vessels Long capillary loops of thicker tumors at the 

border 

Thick melanomas 

Whitish halo in tumors with keratin SCC keratoacanthoma, seborrheic keratosis 

BCC, Basal cell carcinoma; SCC, squamous cell carcinoma. 

JAM ACAD DERMATOL 

JANUARY 2005 

DERMOSCOPIC CRITERIA 

Colors 

The use of dermoscopy allows the identification 

of many different structures and colors, not seen by 

the naked eye. 

Colors play an important role in dermoscopy. 

Common colors are light brown, dark brown, black, 

blue, blue-gray, red, yellow, and white. The most 

important chromophore in melanocytic neoplasms is 

melanin. 11,13,36 The color of melanin essentially 

depends on its localization in the skin. The color 

black is due to melanin located in the stratum 

corneum and the upper epidermis, light to dark 

brown in the epidermis, gray to gray-blue in the 

papillary dermis and steel-blue in the reticular 

dermis. 11,13 The color blue occurs when there is 

melanin localized within the deeper parts of the skin 

because the portions of visible light with shorter 

wavelengths (blue-violet end of spectrum) are more 

dispersed than portions with longer wavelengths 

(red end of visible spectrum). 37,38 The color red is 

associated with an increased number or dilatation of 

blood vessels, trauma, or neovascularization. The 

color white is often caused by regression and/or 

scarring. 11 

Dermoscopic structures 

In this context we will use the nomenclature as 

proposed by the recent Consensus Netmeeting (held 

in Rome in 2001) with some revisions 32 : 

Pigment network. The pigment network is 

a grid-like (honeycomb-like) network consisting 

of pigmented ‘‘lines’’ and hypopigmented 

‘‘holes.’’ 11,13,36,37,39 The anatomic basis of the


VOLUME 52, NUMBER 1 

Fig 1. Two-step procedure for the classification of pigmented 

skin lesions. Adapted from Argenziano G et al. 

J Am Acad Dermatol 2003;48:679-93. 32 

pigment network is either melanin pigment in 

keratinocytes, or in melanocytes along the dermoepidermal 

junction. 40 The reticulation (network) represents 

the rete ridge pattern of the epidermis. 41-43 

The relatively hypomelanotic holes in the network 

correspond to tips of the dermal papillae and the 

overlying suprapapillary plates of the epidermis. 

13,36,37 

The pigment network can be either typical or 

atypical. A typical network is relatively uniform, 

regularly meshed, homogeneous in color, and usually 

thinning out at the periphery. 36,39,44 An atypical 

network is nonuniform, with darker and/or broadened 

lines and ‘‘holes’’ that are heterogeneous in 

area and shape. The lines are often hyperpigmented 

and may end abruptly at the periphery. 36,39,44 

If the rete ridges are short or less pigmented, the 

pigment network may not be visible. Areas devoid of 

any network (but without signs of regression) are 

called ‘‘structureless areas.’’ 11,45 

Dots. Dots are small, round structures less than 

0.1 mm in diameter, which may be black, brown, 

gray, or blue-gray. 11,13,32,36 Black dots are caused by 

pigment accumulation in the stratum corneum and in 

the upper part of the epidermis. 11,37,42,46 Brown dots 

represent focal melanin accumulations at the dermoepidermal 

junction. 47 Gray-blue granules (peppering) 

are caused by tiny melanin structures in the 

papillary dermis. Gray-blue or blue granules are due 

to loose melanin, fine melanin particles or melanin 

‘‘dust’’ in melanophages or free in the deep papillary 

or reticular dermis. 11,37,42,46 

Globules. Globules are symmetrical, round to 

oval, well-demarcated structures that may be brown, 

black, or red. 11,13,32,36 They have a diameter which is 

usually larger than 0.1 mm and correspond to nests 

of pigmented benign or malignant melanocytes, 

clumps of melanin, and/or melanophages situated 

Braun et al 111 

Fig 2. Algorithm for the determination of melanocytic 

versus nonmelanocytic lesions according to the proposition 

of the Board of the Consensus Netmeeting. Adapted 

from Argenziano G et al. J Am Acad Dermatol 2003;48: 

679-93. 32 

usually in the lower epidermis, at the dermoepidermal 

junction, or in the papillary dermis. 11,37,42,46 

Both dots and globules may occur in benign as 

well as in malignant melanocytic proliferations. In 

benign lesions, they are rather regular in size and 

shape and quite evenly distributed (frequently in the 

center of a lesion). 32,36 In melanomas they tend to 

vary in size and shape and are frequently found in 

the periphery of lesions. 32,36,48 

Branched streaks. Branched streaks are an 

expression of an altered pigmented network in which 

the network becomes disrupted or broken up. 11,32,45 

Their pathological correlations are remnants of pigmented 

rete ridges and bridging nests of melanocytic 

cells within the epidermis and papillary dermis. 11 

Radial streaming. Radial streaming appears as 

radially and asymmetrically arranged, parallel linear 

extensions at the periphery of a lesion. 13,49 Histologically, 

they represent confluent pigmented junctional 

nests of pigmented melanocytes. 13,36 

Pseudopods. Pseudopods represent fingerlike 

projections of dark pigment (brown to black) at the 

periphery of the lesion. 13,49,50 They may have small 

knobs at their tips, and are either connected to the 

pigment network or directly connected to the tumor 

body. 13,50 They correspond as well to intraepidermal 

or junctional confluent radial nests of melanocytes. 

13,50 Menzies et al 49 found pseudopods to be 

one of the most specific features of superficial 

spreading melanoma. 

Streaks. ‘‘Streaks’’ is a term used by some 

authors interchangeably with radial streaming or


Fig 3. A, Macroscopic picture of a superficial spreading malignant melanoma (Breslow 

thickness 0.52 mm; Clark level II). B, Dermoscopy of A shows (atypical) pigment network and 

branched streaks and can therefore be considered a melanocytic lesion. 

Fig 4. A, Macroscopic picture of a blue nevus. B, Dermoscopy of A shows steel-blue areas (no 

pigment network, no aggregated globules, no branched streaks). 

Fig 5. A, Macroscopic picture of a seborrheic keratosis. B, Dermoscopy of A shows comedolike 

openings (a), multiple milia-like cysts (b), and fissures (c). 

Fig 6. A, Macroscopic picture of a seborrheic keratosis. B, Dermoscopy of A shows comedolike 

openings and multiple milia-like cysts. 


JANUARY 2005



Fig 7. A, Macroscopic picture of a basal cell carcinoma. B, Dermoscopy of A shows maple 

leafelike areas, ovoid nests, and arborized telangiectasia. 

Fig 8. A, Macroscopic picture of a basal cell carcinoma. B, Dermoscopy of A shows multiple 

spoke wheel areas. 

Fig 9. A, Macroscopic picture of an angioma. B, Dermoscopy of A shows red lagoons. 

pseudopods. This is because both these structures 

have the same histopathological correlation. 11,37,42,46 

Streaks can be irregular, when they are unevenly 

distributed (malignant melanoma), or regular (symmetrical 

radial arrangement over the entire lesion). 

The latter is particularly found in the pigmented 

spindle cell nevi (Reed’s nevi). 51-53 

Structureless areas. Structureless areas represent 

areas devoid of any discernible structures (eg, 

globules, network). They tend to be hypopigmented, 

which is due to the absence of pigment or 

diminution of pigment intensity within a pigmented 

skin lesion. 11 

Blotches. A blotch (also called black lamella by 

some authors) is caused by a large concentration of 


melanin pigment localized throughout the epidermis 

and/or dermis visually obscuring the underlying 

structures. 41-43,46 

Regression pattern. Regression appears as 

white scar-like depigmentation (lighter than the surrounding 

skin) or ‘‘peppering’’ (speckled multiple 

blue-gray granules within a hypopigmented area). 

Histologically, regression shows fibrosis, loss of pigmentation, 

epidermal thinning, effacement of the rete 

ridges, and melanin granules free in the dermis or in 

melanophages scattered in the papillary dermis. 43,46 

Blue-white veil. Blue-white veil is an irregular, 

indistinct, confluent blue pigmentation with 

an overlying white, ground-glass haze. 13,32 The 

pigmentation cannot occupy the entire lesion.


Table II. Pattern analysis according to Pehamberger et al 39 (modified) 

Lentigo simplex Junctional nevus Compound nevus Dermal nevus Blue nevus 

Regular pigment 

network without 

interruptions 

Regular border, thins 

out at periphery 

Black dots over grids 

of pigment 

network 

Brown-black globules 

at center of the 

lesion 



interruptions 



Heterogeneous holes 


network 

Histopathologically this corresponds to an aggregation 

of heavily pigmented cells or melanin in the 

dermis (blue color) in combination with a compact 

orthokeratosis. 13,32,36,43,46,54 

Vascular pattern. Pigmented skin lesions may 

have dermoscopically visible vascular patterns, 

which include ‘‘comma vessels,’’ ‘‘point vessels,’’ 

‘‘tree-like vessels,’’ ‘‘wreath-like vessels,’’ and ‘‘hairpin-like 

vessels’’ (Table I). 55-57 Atypical vascular 

patterns may include linear, dotted, or globular red 

structures irregularly distributed within the lesion. 

32,36,58,59 Some of the vascular patterns may be 

caused by neovascularization. For the evaluation of 

vascular patterns, there has to be as little pressure as 

possible on the lesion during examination because 

otherwise the vessels are simply compressed and 

will not be visible. The use of ultrasound gel for 

immersion helps to reduce the pressure necessary 

for the best evaluation of the skin lesion. 57 

Milia-like cysts. Milia-like cysts are round whitish 

or yellowish structures which are mainly seen in 

seborrheic keratosis.* They correspond to intraepidermal 

keratin-filled cysts and may also be seen in 

congenital nevi as well as in some papillomatous 

melanocytic nevi. At times, milia-like cysts are 

pigmented, and thus, can resemble globules. 

*References 8, 11, 13, 32, 36, 37, 49, 55, 60-63. 

Comedo-like openings (crypts, pseudofollicular 

openings). Comedo-like openings (with 

‘‘blackhead-like plugs’’) are mainly seen in seborrheic 

keratoses or in some rare cases in papillomatous 

melanocytic nevi. y The keratin-filled invaginations 

of the epidermis correspond to the comedo-like 

structures histopathologically. 



interruptions 



Heterogeneous holes 


network 

No criteria for 

melanocytic lesion 

Brown globules Brown globules Homogeneous 

colors 

Homogeneous colors Homogeneous colors Symmetric papular 

appearance 

All criteria for 


possible 

Color heterogeneity 

possible 

Steel-blue areas 

No pigment network No pigment network 

Brown globules lll-defined 

White veils are 

possible 

‘‘Pseudonetwork’’ No pseudonetwork 

‘‘Comma’’-shaped 

blood vessels 


JANUARY 2005 

y References 8, 11, 13, 32, 36, 37, 49, 55, 60-64. 

Fissures and ridges (‘‘brain-like appearance’’). 

Fissures are irregular, linear keratin-filled 

depressions, commonly seen in seborrheic keratoses. 

63 They may also be seen in melanocytic nevi 

with congenital patterns and in some dermal melanocytic 

nevi. Multiple fissures might give a ‘‘brainlike 

appearance’’ to the lesion. 32,36,63,65 This pattern 

has also been named ‘‘gyri and sulci’’ or ‘‘mountain 

and valley pattern’’ by some authors. 11 

Fingerprint-like structures. Some flat seborrheic 

keratoses (also known as solar lentigines) can 

show tiny ridges running parallel and producing 

a pattern that resembles fingerprints. 11,32,65,66 

Moth-eaten border. Some flat seborrheic keratoses 

(mainly on the face) have a concave border 

so that the pigment ends with a curved structure, 

which has been compared to a moth-eaten garment. 

11,13,32,63,65,66 

Leaf-like areas. Leaf-like areas (maple leafelike 

areas) are seen as brown to gray-blue discrete 

bulbous blobs, sometimes forming a leaf-like pattern.* 

Their distribution reminds one of the shape 

of finger pads. In absence of a pigment network, 

they are suggestive of pigmented basal cell carcinoma. 

11,32,67 

*References 8, 9, 11, 13, 32, 36, 37, 39, 55, 65, 

67, 68. 

Spoke wheelelike structures. Spoke wheele 

like structures are well-circumscribed, brown to 

gray-blue-brown, radial projections meeting at 

a darker brown central hub. 11,32,67 In the absence 

of a pigment network, they are highly suggestive of 

basal cell carcinoma.



Table II. Cont’d 

Malignant melanoma Atypical (Clark) nevus Angioma Seborrheic keratosis Pigmented BCC 

Heterogeneous 

(colors and 

structures) 

Asymmetry (colors 

Irregular pigment 

network with 

interruptions 

Table III. ABCD rule of dermoscopy according to Stoiz et al (modified) 11,45 

Large blue-gray ovoid nests. Ovoid nests are 

large, well-circumscribed, confluent or near-confluent, 

pigmented ovoid areas, larger than globules, 

and not intimately connected to a pigmented 

tumor body. 11,32,67 When a network is absent, 

ovoid nests are highly suggestive of basal cell 

carcinoma. 

No features of 


No features for 



No features for 


Heterogeneous holes No pigment network Pigment network Maple-leafelike 

and structures) 

usually absent pigmentation 

Irregular pigment Irregular border Red, red-blue, or Milia-like cysts Telangiectasia 

network 

red-black lagoons, 

( globules, saccules) 

Irregular border with Heterogeneity of Abrupt border cut-off Pseudofollicular Tree-like blood 

abrupt peripheral colors 

openings, 

vessels 

margin 

comedo-like 

openings (plugs) 

Structureless areas Gray-white veil Rough surface ‘‘Dirty’’ gray-brown to 

gray-black colors 

Gray-blue or red-rose Absence of primary 

Abrupt border cut-off 

veils 

criteria for 

malignant 

melanoma 

Red 

Pseudopods/radial 

streaming 

Point and hairpin 

vessels 

Opaque gray-brown 

colors 

Points Weight factor Subscore range 

Asymmetry Complete symmetry 0 1.3 0-2.6 

Asymmetry in 1 axis 1 

Asymmetry in 2 axis 2 

Border 8 segments, 1 point for abrupt cut-off of pigment 0-8 0.1 0-0.8 

Color 1 point for each color: 1-6 0.5 0.5-3.0 

White 

Red 

Light brown 

Dark brown 

Black 

Blue-gray 

Differential structures 1 point for every structure: 1-5 0.5 0.5-2.5 

Pigment network 

Structureless areas 

Dots 

Globules 

Streaks 

Total score range: 1.0-8.9 

Multiple blue-gray globules. Multiple bluegray 

globules are round, well-circumscribed structures 

that are, in the absence of a pigment network, 

highly suggestive of basal cell carcinoma. 11,32,67 

They have to be differentiated from multiple bluegray 

dots (which correspond to melanophages and 

melanin dust).


Table IV. The 7-point checklist according to 

Argenziano et al 44 

Criteria 

Major criteria 

7-point score 

Atypical pigment network 2 

Blue-white veil 2 

Atypical vascular pattern 

Minor criteria 

2 

Irregular streaks 1 

Irregular pigmentation 1 

Irregular dots/globules 1 

Regression structures 1 

DIFFERENTIAL DIAGNOSIS OF 

PIGMENTED LESIONS OF THE SKIN 

There are many publications on the subject of the 

differential diagnosis of pigmented lesions of the 

skin. The 5 algorithms most commonly used are 

pattern analysis 8,39,62 ; the ABCD rule of dermoscopy 

11,45,70 ; the 7-point checklist 32,36,44 ; the 

Menzies method 13,32,49 ; and the revised pattern 

analysis. 71 

The Board of the Consensus Netmeeting agreed 

on a two-step procedure for the classification of 

pigmented lesions of the skin (Fig 1). A similar 

approach has been proposed by other authors in 

the past. 

The first step is the differentiation between 

a melanocytic and a nonmelanocytic lesion. For 

this decision, the algorithm in Fig 2 is used. 

Are aggregated globules, pigment network, 

branched streaks (Fig 3), homogeneous blue pigmentation 

(blue nevus: Fig 4), or a parallel pattern 

(palms, soles, and mucosa) visible? If this is the case, 

the lesion should be considered as a melanocytic 

lesion (Fig 3). If not, the lesion should be evaluated 

for the presence of comedo-like plugs, multiple 

milia-like cysts, and comedo-like openings, irregular 

crypts, light brown fingerprint-like structures, or 

‘‘fissures and ridges’’ (brain-like appearance) pattern. 

If so, the lesion is suggestive of a seborrheic 

keratosis (Figs 5 and 6). If not, the lesion has to be 

evaluated for the presence of arborizing blood 

vessels (telangiectasia), leaf-like areas, large bluegray 

ovoid nests, multiple blue-gray globules, spoke 

wheel areas, or ulceration. If present, the lesion is 

suggestive of basal cell carcinoma (Figs 7 and 8). If 

not, one has to look for red or red-blue (to black) 

lagoons. If these structures are present, the lesion 

should be considered a hemangioma (Fig 9) oran 

angiokeratoma. If all the preceding questions were 

answered with ‘‘no,’’ the lesion should still be 

considered to be a melanocytic lesion. 

Table V. ‘‘The Menzies Method’’ according to 

Menzies et al 13,49 

Negative features 

Point and axial symmetry of pigmentation 

Presence of a single color 

Positive features 

Blue-white veil 

Multiple brown dots 

Pseudopods 

Radial streaming 

Scar-like depigmentation 

Peripheral black dots-globules 

Multiple colors (5 or 6) 

Multiple blue/gray dots 

Broadened network 


JANUARY 2005 

Once the lesion is identified to be of melanocytic 

origin, the decision has to be made if the melanocytic 

lesion is benign, suspect, or malignant. To accomplish 

this, 4 different approaches are the most 

commonly used. 

Pattern analysis (Pehamberger et al) 

Pattern recognition has historically been used by 

clinicians and histopathologists to differentiate benign 

lesions from malignant neoplasms. A similar 

process has been found useful with dermoscopy, 

and has been termed ‘‘pattern analysis.’’ It allows 

distinction between benign and malignant growth 

features. It was described by Pehamberger and 

colleagues based on the analysis of more than 7000 

pigmented skin lesions. 8,39,62 Table II shows the 

typical patterns of some common, pigmented skin 

lesions using pattern analysis. 

ABCD rule of dermatoscopy (Stolz et al) 

The ABCD rule of dermatoscopy, described by 

Stolz et al in 1993 was based on an analysis of 157 

pigmented skin lesions. 11,70 The complete ABCD 

rule is explained in Table III. 

For the evaluation of asymmetry, the lesion is 

divided into 4 segments (2 perpendicular axes). The 

axes are oriented so that the lowest asymmetry is 

obtained. For asymmetry in both axes, a value of 2 is 

obtained. To calculate the subscore, the value of each 

ABCD category has to be multiplied by the corresponding 

weight factor. To obtain the total score 

value, the different ABCD subscores have to be 

added. 

The total score ranges from 1 to 8.9. A lesion with 

a total score greater than 5.45 should be considered 

as melanoma. A lesion with a total score of 4.75 

or less can be considered as benign. A lesion with 

a score value between 4.75 and 5.45 should be



Table VI. Pattern of benign and malignant lesions 

Benign Malignant 

Dots Centrally located or situated right on the Unevenly distributed and scattered focally at 

network 

the periphery 

Globules Uniform in size, shape, and color, symmetrically Globules that are unevenly distributed and 

located at the periphery, centrally located, or when reddish are highly suggestive of 

uniform throughout the lesion as in a 

cobblestone pattern 

melanoma 

Streaks Radial streaming or pseudopods tend to be Radial streaming or pseudopods tend to be 

symmetrical and uniform at the periphery focal and irregular at periphery 

Blue-white veil Tends to be centrally located Tends to be asymmetrically located or diffuse 

almost over entire lesion 

Blotch Centrally located or may be diffuse 

Asymmetrically located or there are often 

hyperpigmented area that extends almost to 

periphery of the lesion 

multiple asymmetrical blotches 

Network Typical network that consists of light to dark Atypical network that may be nonuniform with 

uniform pigmented lines and 

black/brown or gray thickened lines and 

hypopigmented holes 

holes of different sizes and shapes 

Network borders Either fades into the periphery or is 

symmetrically sharp 

Focally sharp 

considered ‘‘suspicious’’ and should therefore be 

monitored closely or removed. 11,70 

7-point checklist 

In 1998 Argenziano and colleagues described a 7point 

checklist based on the analysis of 342 pigmented 

skin lesions. 32,36,44 They distinguish 3 major 

criteria and 4 minor criteria (Table IV). Each major 

criterion has a score of 2 points while each minor 

criterion has a score of 1 point. A minimum total 

score of 3 is required for the diagnosis of malignant 

melanoma. 

Menzies method 

In the Menzies method 13,32,49 for diagnosing 

melanoma, both of the following negative features 

must not be found: a single color (tan, dark brown, 

gray, black, blue, and red, but white is not considered) 

and ‘‘point and axial symmetry of pigmentation’’ 

(refers to pattern symmetry around any axis 

through the center of the lesion). This does not 

require the lesion to have symmetry of shape. 

Additionally, at least one positive feature must be 

found (Table V). 

Exceptions to the algorithms 

The ABCD rule is not applicable for pigmented 

lesions on the palms, soles, or face. 11 Palms and soles 

have a particular anatomy which is characterized by 

marked orthokeratosis and the presence of sulci and 

gyri. The sweat ducts join the surface at the summits 

of the gyri. 11,32 A classification of 10 different 

dermoscopy patterns on the palms and soles has 

been proposed by Saida et al. 72 


The face has a very particular anatomic architecture 

especially concerning the dermoepidermal 

junction where rete ridges are shorter. That is why 

facial lesions often do not exhibit a regular pigment 

network. Dermoscopy shows a broadened pigment 

reticulation which is called a ‘‘pseudonetwork.’’ This 

does not correspond to the projection of pigmented 

rete ridges. It is due to a homogeneous pigmentation 

which is interrupted by the surface openings of the 

adnexal structures. 11,66,73 

The differential diagnosis of a pseudonetwork is 

solar lentigo, seborrheic keratosis, lentigo simplex, 

melanoma in situ, lichen planuselike keratosis, and 

pigmented actinic keratosis. 11,66,73 These lesions 

are often difficult to distinguish dermoscopically. 

However, when there are multiple colors and 

a broadened, thickened, and irregular ‘‘pseudonetwork,’’ 

melanoma is often the diagnosis suggested. 

Other, more specific characteristics include an ‘‘annular 

granular’’ or ‘‘rhomboidal pattern.’’ 11,66,73 

Revised pattern analysis 

The overall general appearance of color, architectural 

order, symmetry of pattern, and homogeneity 

(CASH) are important components in distinguishing 

these two groups. Benign melanocytic lesions tend 

to have few colors, architectural order, symmetry of 

pattern, or homogeneity. Malignant melanoma often 

has many colors and much architectural disorder, 

asymmetry of pattern, and heterogeneity. 

The reticular pattern or network pattern is the 

most common global feature in melanocytic lesions. 

This pattern represents the junctional component


of a melanocytic nevus (Clark nevus, dysplastic 

nevus). 32,36,71 

Another pattern is the so-called globular pattern. 

It is characterized by the presence of numerous 

‘‘aggregated globules.’’ This pattern is commonly 

seen in a congenital nevus, superficial type. 32,36,71 

The cobblestone pattern is very similar to the 

globular pattern but is composed of closer aggregated 

globules, which are somehow angulated, resembling 

cobblestones. 

The homogeneous pattern appears as diffuse 

pigmentation, which might be brown, gray-blue, 

gray-black, or reddish black. 32,36,71 No pigment 

network or any other distinctive dermoscopy structure 

is found. An example is the homogeneous steelblue 

color seen in blue nevi. 

The so-called starburst pattern is characterized by 

the presence of streaks in a radial arrangement, 

which is visible at the periphery of the lesion. 32,36,71 

This pattern is commonly seen in Reed nevi or Spitz 

nevi. 

The parallel pattern is exclusively found on the 

palms and soles due to the particular anatomy of 

these areas. 32,36,71 

The combination of 3 or more distinctive dermoscopic 

structures (ie, network, dots, and globules as 

well diffuse areas of hyperpigmentation and hypopigmentation) 

within a given lesion is called multicomponent 

pattern. 32,36,71 This pattern is highly 

suggestive of melanoma, but might be observed in 

some cases in acquired melanocytic nevi and congenital 

nevi. 

The term ‘‘lesions with indeterminate patterns’’ 

are dermoscopic patterns that can be seen in both 

benign and malignant pigmented lesions. Clinically 

and dermoscopically, one cannot make a distinction 

between whether they are melanomas or atypical 

nevi. 

In addition to the global features already mentioned, 

the local features (dermoscopic structures 

such as the pigment network, dots, and globules, etc) 

are important to evaluate melanocytic lesions 

(Table VI). 

PERSPECTIVES 

Because computer hardware has become userfriendly 

and more affordable, digital dermoscopy 

will become more integrated into the clinical setting. 

The currently available digital dermoscopic systems 

already have an acceptable picture quality which 

comes close to a photograph. 74 Digital images offer 

the possibility of computer storage and retrieval of 

dermoscopic images and patient data. 48,75-78 Some 

systems even offer the potential of ‘‘computerassisted 

diagnosis.’’ 79-94 Because diagnostic accuracy 


JANUARY 2005 

with dermoscopy has been shown to depend on the 

experience of the dermatologist, such objective 

systems might help less-experienced dermatologists 

in the future. 

Another expanding field is teledermoscopy. At 

the beginning of the digital dermoscopic era, teledermoscopy 

was used between experts to exchange 

difficult or interesting images. The development of 

new electronic media and the evolution of the 

Internet will have an important impact as the infrastructure 

becomes available to almost everyone, 

and the exchange is now easy to perform. Recent 

studies were able to show the feasibility and importance 

of teledermoscopy. 95-98 This was recently used 

in a Consensus Netmeeting on Dermoscopy held in 

Rome during the first World 57,69 Congress on Dermoscopy 

(http://www.dermoscopy.org). 32 

We thank Dr G. Argenziano, Dr J. Kreusch, Professor S. 

Menzies, Professor H. Pehamberger, and Professor W. 

Stolz for their suggestions and their permission for the 

reproductions. We also thank Dr S. Rabinovitz for her help 

during the entire editing process and for her valuable 

suggestions. 

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