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DERMOSCOPY: THE ESSENTIALS, THIRD EDITION ISBN: 978-0-7020-6882-9
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Preface to the Third Edition
As we prepare the third edition of Dermoscopy: The We are especially indebted to the Elsevier Editorial
Essentials, it has been 14 years since the first edition Team, Caroline Dorey-Stein and Charlotta Kryhl,
and 6 years since we last updated our guidebook to for their flexible support and patience during the
dermoscopy. With dermoscopy continuing to grow slow process of revising the book. We also thank our
in popularity as a physician’s tool, we are pleased to colleagues Dr Teresa Russo, Glen Wimberley and Katie
revamp our book and bring it to a new generation of Lee for their assistance in selecting and preparing the
dermoscopists. As always, it is a pleasure to collab- updated images and text.
orate with old colleagues and peers, though we are As with the earlier editions, we consign our
scattered around the world. We are able to work hand- book to all those interested in the science and art of
in-glove despite the vast distances with the miracle of dermoscopy and hope that we contribute to the lofty
modern technology and with the advantage of having goal of eradicating melanoma.
known each other and worked together for many H. Peter Soyer
years (over 20 years in some cases), and having been Brisbane, Australia
through many highs and lows together. Giuseppe Argenziano
This third edition continues to use the traffic Naples, Italy
light system to help practitioners quickly review Rainer Hofmann-Wellenhof
lesion categories during regular use and consolidate Graz, Austria
their knowledge, and to help new users absorb Iris Zalaudek
the skill of evaluating a whole lesion as well as its Trieste, Italy
component parts. We have substituted nearly 30% of 2018
the dermoscopic and clinical images to bring a fresh
set of clinically relevant examples to both novice and
experienced dermoscopists.
KEY TO TRAFFIC LIGHT SYMBOLS
High risk lesions
Moderate risk lesions
Low risk lesions
v
Acknowledgements
To my Oz-based team, Zoja and Niko, for both their To my “dermoscopy” friends and colleagues, to my
support and welcome distraction from my work. patients, and to my parents Ilse and Gunter, my sister
H. Peter Soyer Karin, my niece Lilith, and my nephew Arthur for
their love.
To my patients…to whom I have dedicated my life. Iris Zalaudek
Giuseppe Argenziano
To my teacher in dermoscopy and to my friends in
the field of dermoscopy. Special thanks go to my wife
Andrea and my children Elisabeth, Paul, Martin and
Georg, who have given me the strength to joyfully
work on the book.
Rainer Hofmann-Wellenhof
vii
DERMOSCOPY
The Essentials
THIRD EDITION
H. Peter Soyer, MD, FACD
Professor and Chair,
Dermatology Research Centre,
The University of Queensland Diamantina
Institute,
The University of Queensland
and
Princess Alexandra Hospital,
Brisbane, Australia
Giuseppe Argenziano, MD
Professor of Dermatology,
Dermatology Unit,
University of Campania, Naples, Italy
Rainer Hofmann-Wellenhof,
MD
Professor of Dermatology,
Research Unit for Teledermatology, Prevention
and
Innovative Diagnostic Technologies in Dermato-
Oncology,
Department of Dermatology,
Medical University Graz,
Graz, Austria
Iris Zalaudek, MD
Professor of Dermatology,
Department of Dermatology and Venereology,
University of Trieste,
Trieste, Italy
1
Introduction: The 3-point
checklist
The short, easy way to avoid missing a melanoma using
dermoscopy
Other names for dermoscopy of patients with pigmented skin lesions, there is a
wide variety of products to choose from.
Dermatoscopy
Epiluminescence microscopy (ELM)
The 3-point checklist
Skin surface microscopy
To encourage clinicians to start using dermoscopy,
simplified algorithms for analyzing what is seen with
the technique have been developed.
Dermoscopy is an in vivo noninvasive diagnostic
For the novice dermoscopist, the primary goal of
technique that magnifies the skin in such a way that
dermoscopy is to determine whether a suspicious
color and structure in the epidermis, dermoepidermal
lesion should be biopsied or excised. The bottom
junction, and papillary dermis become visible. This
line is that no patient should leave the clinic with an
color and structure cannot be seen with the naked
undiagnosed melanoma.
eye. With training and experience, dermoscopy has
For the general physician, dermoscopy can be used
been shown to significantly increase the clinical
to determine whether a suspicious lesion should be
diagnosis of melanocytic, non-melanocytic, benign
evaluated by a more experienced clinician.
and malignant skin lesions, with a 10–27% improve-
Dermoscopy is not just for dermatologists; any
ment in the diagnosis of melanoma compared to
clinician who is interested can master this potentially
that achieved by clinical examination alone. There is,
life-saving technique.
however, a learning curve to mastering dermoscopy,
and it is essential to spend time perfecting it—practice
Triage of suspicious pigmented skin lesions
makes perfect!
The 3-point checklist was developed specifically for nov-
ice dermoscopists with little training to help them not
Technique
to misdiagnose melanomas while improving their skills.
In classic dermoscopy, oil or fluid (mineral oil, Results of the 2001 Consensus Net Meeting on
immersion oil, KY jelly, alcohol, water) is placed over Dermoscopy (Argenziano G, J Am Acad Dermatol
the lesion to be examined. Fluid eliminates surface 2003) showed that the following three criteria were
light reflection and renders the stratum corneum especially important in distinguishing melanomas
transparent, allowing visualization of subsurface from other benign pigmented skin lesions:
colors and structures. Using handheld dermoscopes
• d ermoscopic asymmetry of color and structure;
that exploit the properties of cross-polarized light
• a typical pigment network; and
(polarized dermoscopy), visualization of deep skin
• b lue-white structures (a combination of the
structures can be achieved without the necessity of a
previous categories of blue-white veil and regres-
liquid interface or direct skin contact with the instru-
sion structures).
ment.
The list of dermoscopy instrumentation is long Statistical analysis showed that the presence of any
and continues to grow and evolve with the devel- two of these criteria indicates a high likelihood of
opment of better and more sophisticated handheld melanoma. Using the 3-point checklist, one can have
instruments and computer systems. Depending on the a sensitivity and specificity result comparable with
budget and goals for the evaluation and management other algorithms requiring much more training. In a
1
s preliminary study of 231 clinically equivocal pig- Table 1.1 Definition of dermoscopic criteria for the
al
ti mented skin lesions, it was shown that, after a short 3-point checklist. The presence of two or three
n
e introduction of 1-h duration, six inexperienced der- criteria is suggestive of a suspicious lesion
ss moscopists were able to classify 96.3% of melanomas
E correctly using this method.
e 3-Point checklist Definition
h This first chapter provides 60 examples of benign
T and malignant pigmented skin lesions to demonstrate 1. Asymmetry Asymmetry of color and
–
Y how the 3-point checklist works and the practical structure in one or two
P value of this simplified diagnostic algorithm. perpendicular axes
O
The 3-point checklist was designed to be used as 2. Atypical network Pigment network with
C
S a screening method. The sensitivity is much higher irregular holes and thick
O than the specificity to ensure that melanomas are not lines
M misdiagnosed. We recommend that all lesions with
3. Blue-white structures Any type of blue and/or
R
a positive test (3-point checklist score of 2 or 3) are
E white color
D excised (Table 1).
2
1
Checklist Int
r
o
d
Asymmetry u
c
t
Atypical network io
n
: T
Blue-white structures h
e
(cid:13) Total score 3 3-
p
o
in
(cid:13) t
c
h
e
c
k
(cid:13) lis
t
Fig. 1 Melanoma.
Criteria to diagnose melanoma can be very subtle or obviously present as in this case. This lesion clearly
demonstrates all of the 3-point checklist criteria, namely asymmetry in all axes, an atypical pigment net-
work (circle), and blue-white structures (asterisks).
Checklist
Asymmetry
Atypical network
Blue-white structures
0
Total score
Fig. 2 Nevus.
In contrast to Fig. 1, none of the features of the 3-point checklist are seen in this lesion. The lesion is
symmetrical, and the pigment network is regular, although it might seem to be atypical because the line
segments are slightly thickened. Also there is no hint of any blue and/or white color.
3
s
al Checklist
ti
n
e Asymmetry
s
s
E Atypical network
e
h
T Blue-white structures
–
Y 1
Total score
P
O
C
S
O
M
R
E
D
Fig. 3 Nevus.
The novice might find this lesion difficult to diagnose. If in doubt, cut it out! With experience, the clinician
will excise fewer of these banal nevi. There is asymmetry; however, neither an atypical pigment network
nor subtle blue-white structures are present.
Checklist
Asymmetry
Atypical network
Blue-white structures
Total score 2
Fig. 4 Melanoma.
Even for a beginner, the asymmetry of color and structure should be obvious. This asymmetrical lesion
also demonstrates blue-white structures (circle).
4
1
Checklist Int
r
o
d
Asymmetry u
c
t
Atypical network io
n
: T
Blue-white structures h
e
Total score 3 3-
p
o
in
t
c
h
e
c
k
lis
t
Fig. 5 Melanoma.
The color and structure in the lower half is not a mirror image of the upper half; therefore, there is asym-
metry. An atypical pigment network with thickened and broken-up line segments (circle) and a large area
of blue-white structures (arrows) are also seen.
Checklist
Asymmetry
Atypical network
Blue-white structures
Total score 2
Fig. 6 Melanoma.
This lesion is slightly asymmetric in shape and more in structure, and therefore, a red flag should be
raised. No pigment network is present, but there are numerous shiny white streaks (also called chrysa-
lis-like structures) (arrows) representing a variation on the theme of blue-white structures.
5
