Dermoscopy of pigmented skin lesions
Ralph Peter Braun, MD,aHarold S. Rabinovitz, MD,bMargaret Oliviero, ARNP, MSN,b
Alfred W. Kopf, MD,cand Jean-Hilaire Saurat, MDa
Geneva, Switzerland; Miami, Florida; and New York, New York
Dermoscopy is an in vivo method for the early diagnosis of malignant melanoma and the differential
diagnosis of pigmented lesions of the skin. It has been shown to increase diagnostic accuracy over clinical
visual inspection in the hands of experienced physicians. This article is a review of the principles of
dermoscopy as well as recent technological developments. ( J Am Acad Dermatol 2005;52:109-21.)
metastatic melanoma, the best treatment currently
the primary cancer.5,7Dermoscopy (also known as
epiluminescence microscopy, dermatoscopy, and
amplified surface microscopy) is an in vivo method,
recognition of malignant melanoma.8-11The perfor-
mance 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.12-16This was confirmed by recent
evidence-based publications and based on a meta-
the principles of dermoscopy as well as recent
n the last two decades a rising incidence of
malignant melanoma has been observed.1-7
Because of a lack of adequate therapies for
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.11,19In 1878,
Abbe described the use of immersion oil in light
microscopy20and this principle was transferred to
skin surface microscopy by the German dermatolo-
gist, Unna, in 1893.21He introduced the term
‘‘diascopy’’ and described the use of immersion oil
and a glass spatula for the interpretation of lichen
planus and forthe evaluation of theinfiltrate in lupus
erythematosus. The term ‘‘dermatoscopy’’ was in-
troduced in 1920 by the German dermatologist
Johann Saphier who published a series of commu-
nications using a new diagnostic tool resembling
a binocular microscope with a built-in light source
fortheexamination oftheskin.22-25Heused thisnew
tool in various indications and did some interesting
morphological observations on anatomical struc-
tures of the skin which indicated the high perfor-
mance of his equipment. Skin surface microscopy
was further developed in the United States by
Goldman in the 1950s. He published a series of
interesting articles on new devices on what he called
‘‘Dermoscopy.’’26-29He was the first dermatologist to
use this new technique for the evaluation of pig-
mented skin lesions. In 1971, Rona MacKie30clearly
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 Hamburg31and the
Consensus Netmeeting on Dermoscopy, which was
held in 2001 in Rome32(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
From the Pigmented Skin Lesion Unit, Department of Dermatol-
ogy, University Hospital Genevaa; Skin and Cancer Associates,
Plantation, Fla, and Department of Dermatology, University of
Miami School of Medicineb; and The Ronald O. Perelman
Department of Dermatology, New York University School of
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: firstname.lastname@example.org.
ª 2005 by the American Academy of Dermatology, Inc.
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 ade-
quately visualized. However, when various immer-
sion liquids are used, they render the skin surface
translucent and reduce the reflection, so that un-
derlying structures are readily visible. The applica-
tion 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.34,35Specially de-
signed handheld devices with 10 to 20 times magni-
fication are commercially available (Dermatoscope
Pra ¨zisionsoptik]; Episcope [Welch-Allyn]; DermLite
[3Gen, LLC]). Photographic documentation can be
performed with a dermoscopic attachment to a stan-
dard 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 dermatol-
ogists with less experience in dermoscopy, some of
the systems may offer the possibility of computer-
assisted diagnosis for malignant melanoma or for
consulting an expert through telemedicine.
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
melanin.11,13,36The 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.11,13The 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).37,38The 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
In this context we will use the nomenclature as
proposed by the recent Consensus Netmeeting (held
in Rome in 2001) with some revisions32:
Pigment network. The pigment network is
a grid-like (honeycomb-like) network consisting
of pigmented ‘‘lines’’
The anatomic basis of the
Table I. Vascular architecture of pigmented skin lesions according to Kreusch and Koch57
Morphological aspectType of pathology
Tree-like vessels Thick, arborizing vessels, superficial Pigmented BCC of any type (discrete in
Sebaceous gland hyperplasiaCorona vessels ‘‘Surround’’ the tumor
Thinner than tree-like vessels
Less curved than tree-like vessels
Short, strong, curved,
Located on the tumor
Short distance, parallel to skin surface
Short capillary loops
Dense packed red points
Not in the holes of the pigment network
Long capillary loops of thicker tumors at the
Whitish halo in tumors with keratin
Comma-shaped vessels Dermal nevi
Point vessels Thin malignant melanomas
Epithelial tumors such as actinic keratosis,
Bowen’s disease, etc (short vertical height)
Thick melanomas Hairpin vessels
SCC keratoacanthoma, seborrheic keratosis
BCC, Basal cell carcinoma; SCC, squamous cell carcinoma.
J AM ACAD DERMATOL
110 Braun et al
pigment network is either melanin pigment in
keratinocytes, or in melanocytes along the dermoe-
pidermal junction.40The reticulation (network) rep-
resents the rete ridge pattern of the epidermis.41-43
The relatively hypomelanotic holes in the network
correspond to tips of the dermal papillae and the
overlying suprapapillary plates of the epider-
The pigment network can be either typical or
atypical. A typical network is relatively uniform,
regularly meshed, homogeneous in color, and usu-
ally thinning out at the periphery.36,39,44An atypical
network is nonuniform, with darker and/or broad-
ened 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.11,13,32,36Black dots are caused by
the upper part of the epidermis.11,37,42,46Brown dots
represent focal melanin accumulations at the der-
moepidermal junction.47Gray-blue granules (pep-
pering) 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.11,13,32,36They 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
usually in the lower epidermis, at the dermoepider-
mal 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).32,36In 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
the network becomes disrupted or broken up.11,32,45
Their pathological correlations are remnants of pig-
mented 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.13,49Histo-
logically, they represent confluent pigmented junc-
tional nests of pigmented melanocytes.13,36
Pseudopods. Pseudopods represent fingerlike
projections of dark pigment (brown to black) at the
periphery of the lesion.13,49,50They may have small
knobs at their tips, and are either connected to the
pigment network or directly connected to the tumor
body.13,50They correspond as well to intraepidermal
or junctional confluent radial nests of melano-
cytes.13,50Menzies et al49found pseudopods to be
one of the most specific features of superficial
Streaks. ‘‘Streaks’’ is a term used by some
authors interchangeably with radial streaming or
Fig 2. Algorithm for the determination of melanocytic
versus nonmelanocytic lesions according to the proposi-
tion of the Board of the Consensus Netmeeting. Adapted
from Argenziano G et al. J Am Acad Dermatol 2003;48:
Fig 1. Two-step procedure for the classification of pig-
mented skin lesions. Adapted from Argenziano G et al.
J Am Acad Dermatol 2003;48:679-93.32
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al111
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 6. A, Macroscopic picture of a seborrheic keratosis. B, Dermoscopy of A shows comedo-
like openings and multiple milia-like cysts.
Fig 5. A, Macroscopic picture of a seborrheic keratosis. B, Dermoscopy of A shows comedo-
like openings (a), multiple milia-like cysts (b), and fissures (c).
J AM ACAD DERMATOL
112 Braun et al
pseudopods. This is because both these structures
have thesamehistopathological correlation.11,37,42,46
Streaks can be irregular, when they are unevenly
distributed (malignant melanoma), or regular (sym-
metrical 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 repre-
sent areas devoid of any discernible structures (eg,
globules, network). They tend to be hypopig-
mented, which is due to the absence of pigment or
diminution of pigment intensity within a pigmented
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
Regressionpattern. Regression appears as
white scar-like depigmentation (lighter than the sur-
rounding skin) or ‘‘peppering’’ (speckled multiple
blue-gray granules within a hypopigmented area).
Histologically, regression shows fibrosis, loss of pig-
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 irregu-
lar, indistinct, confluent blue pigmentation with
an overlying white, ground-glass haze.13,32The
pigmentation cannot occupy the entire lesion.
Fig 8. A, Macroscopic picture of a basal cell carcinoma. B, Dermoscopy of A shows multiple
spoke wheel areas.
Fig 7. A, Macroscopic picture of a basal cell carcinoma. B, Dermoscopy of A shows maple
leafelike areas, ovoid nests, and arborized telangiectasia.
Fig 9. A, Macroscopic picture of an angioma. B, Dermoscopy of A shows red lagoons.
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al113
Histopathologically this corresponds to an aggrega-
tion of heavily pigmented cells or melanin in the
dermis (blue color) in combination with a compact
Vascular pattern. Pigmented skin lesions may
have dermoscopically visible vascular patterns,
which include ‘‘comma vessels,’’ ‘‘point vessels,’’
‘‘tree-like vessels,’’ ‘‘wreath-like vessels,’’ and ‘‘hair-
pin-like vessels’’ (Table I).55-57Atypical vascular
patterns may include linear, dotted, or globular red
structures irregularly distributed within the le-
sion.32,36,58,59Some 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 whit-
ish or yellowish structures which are mainly seen in
seborrheic keratosis.* They correspond to intraepi-
dermal 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, pseudofollic-
‘‘blackhead-like plugs’’) are mainly seen in sebor-
rheic keratoses or in some rare cases in papilloma-
tous melanocytic nevi.yThe keratin-filled invaginations
of the epidermis correspond to the comedo-like
yReferences 8, 11, 13, 32, 36, 37, 49, 55, 60-64.
Fissures and ridges (‘‘brain-like appear-
ance’’). Fissures are irregular, linear keratin-filled
depressions, commonly seen in seborrheic kerato-
ses.63They may also be seen in melanocytic nevi
with congenital patterns and in some dermal mela-
nocytic nevi. Multiple fissures might give a ‘‘brain-
like appearance’’ to the lesion.32,36,63,65This pattern
has also been named ‘‘gyri and sulci’’ or ‘‘mountain
and valley pattern’’ by some authors.11
Fingerprint-like structures. Some flat sebor-
rheic 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 kera-
toses (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 gar-
Leaf-like areas. Leaf-like areas (maple leafelike
areas) are seen as brown to gray-blue discrete
bulbous blobs, sometimes forming a leaf-like pat-
tern.* Their distribution reminds one of the shape
of finger pads. In absence of a pigment network,
they are suggestive of pigmented basal cell car-
*References 8, 9, 11, 13, 32, 36, 37, 39, 55, 65,
Spoke wheelelike structures. Spoke wheele
like structures are well-circumscribed, brown to
gray-blue-brown, radial projections meeting at
a darker brown central hub.11,32,67In the absence
of a pigment network, they are highly suggestive of
basal cell carcinoma.
Table II. Pattern analysis according to Pehamberger et al39(modified)
Lentigo simplexJunctional nevus Compound nevus Dermal nevusBlue nevus
Regular border, thins
out at periphery
Black dots over grids
at center of the
Regular border, thins
out at periphery
Regular border, thins
out at periphery
No criteria for
No pigment networkNo pigment network
White veils are
Homogeneous colorsSymmetric papular
All criteria for
J AM ACAD DERMATOL
114 Braun et al
Large blue-gray ovoid nests. Ovoid nests are
large, well-circumscribed, confluent or near-con-
fluent, pigmented ovoid areas, larger than glob-
ules, and not intimately connected to a pigmented
tumor body.11,32,67When a network is absent,
ovoid nests are highly suggestive of basal cell
Multiple blue-gray globules. Multiple blue-
gray globules are round, well-circumscribed struc-
tures 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 blue-
gray dots (which correspond to melanophages and
Table III. ABCD rule of dermoscopy according to Stoiz et al (modified)11,45
Points Weight factor Subscore range
Asymmetry Complete symmetry
Asymmetry in 1 axis
Asymmetry in 2 axis
8 segments, 1 point for abrupt cut-off of pigment
1 point for each color:
1 point for every structure:
Differential structures 1-5 0.5 0.5-2.5
Total score range: 1.0-8.9
Table II. Cont’d
Malignant melanoma Atypical (Clark) nevus AngiomaSeborrheic keratosisPigmented BCC
No features of
No features for
No features for
No pigment network Pigment network
Irregular border Red, red-blue, or
Abrupt border cut-off
Irregular border with
Structureless areas Gray-white veil‘‘Dirty’’ gray-brown to
Gray-blue or red-rose
Absence of primary
Abrupt border cut-off
Red Opaque gray-brown
Point and hairpin
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al115
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 analysis8,39,62; the ABCD rule of dermo-
scopy11,45,70; the 7-point
Menzies method13,32,49; and the revised pattern
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 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 pig-
mentation (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) pat-
tern. 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 blue-
gray 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) or an
angiokeratoma. If all the preceding questions were
answered with ‘‘no,’’ the lesion should still be
considered to be a melanocytic lesion.
Once the lesion is identified to be of melanocytic
lesion is benign, suspect, or malignant. To accom-
plish this, 4 different approaches are the most
Pattern analysis (Pehamberger et al)
Pattern recognition has historically been used by
clinicians and histopathologists to differentiate be-
nign 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.8,39,62Table 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.11,70The 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
ABCD category has to be multiplied by the corre-
sponding weight factor. To obtain the total score
value, the different ABCD subscores have to be
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 IV. The 7-point checklist according to
Argenziano et al44
Criteria 7-point score
Atypical pigment network
Atypical vascular pattern
Table V. ‘‘The Menzies Method’’ according to
Menzies et al13,49
Point and axial symmetry of pigmentation
Presence of a single color
Multiple brown dots
Peripheral black dots-globules
Multiple colors (5 or 6)
Multiple blue/gray dots
J AM ACAD DERMATOL
116 Braun et al
considered ‘‘suspicious’’ and should therefore be
monitored closely or removed.11,70
In 1998 Argenziano and colleagues described a 7-
point checklist based on the analysis of 342 pig-
mented skin lesions.32,36,44They 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
In the Menzies method13,32,49for 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 consid-
ered) and ‘‘point and axial symmetry of pigmenta-
tion’’ (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
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.11,32A 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 architec-
ture 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
The differential diagnosis of a pseudonetwork is
solar lentigo, seborrheic keratosis, lentigo simplex,
melanoma in situ, lichen planuselike keratosis, and
pigmented actinic keratosis.11,66,73These lesions
are often difficult to distinguish dermoscopically.
However, when there are multiple colors and
a broadened, thickened, and irregular ‘‘pseudonet-
work,’’ melanoma is often the diagnosis suggested.
Other, more specific characteristics include an ‘‘an-
nular granular’’ or ‘‘rhomboidal pattern.’’11,66,73
Revised pattern analysis
The overall general appearance of color, architec-
tural 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
Table VI. Pattern of benign and malignant lesions
Dots Centrally located or situated right on the
Uniform in size, shape, and color, symmetrically
located at the periphery, centrally located, or
uniform throughout the lesion as in a
Radial streaming or pseudopods tend to be
symmetrical and uniform at the periphery
Tends to be centrally located
Unevenly distributed and scattered focally at
Globules that are unevenly distributed and
when reddish are highly suggestive of
Streaks Radial streaming or pseudopods tend to be
focal and irregular at periphery
Tends to be asymmetrically located or diffuse
almost over entire lesion
Asymmetrically located or there are often
multiple asymmetrical blotches
Blotch Centrally located or may be diffuse
hyperpigmented area that extends almost to
periphery of the lesion
Typical network that consists of light to dark
uniform pigmented lines and
Either fades into the periphery or is
Atypical network that may be nonuniform with
black/brown or gray thickened lines and
holes of different sizes and shapes
Focally sharp Network borders
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al 117
of a melanocytic nevus (Clark nevus, dysplastic
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 aggre-
gated globules, which are somehow angulated, re-
The homogeneous pattern appears as diffuse
pigmentation, which might be brown, gray-blue,
gray-black, or reddish black.32,36,71No pigment
network or any other distinctive dermoscopy struc-
ture is found. An example is the homogeneous steel-
blue 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
The parallel pattern is exclusively found on the
palms and soles due to the particular anatomy of
The combination of 3 or more distinctive dermo-
scopic structures (ie, network, dots, and globules as
well diffuse areas of hyperpigmentation and hypo-
pigmentation) within a given lesion is called multi-
component pattern.32,36,71This pattern is highly
suggestive of melanoma, but might be observed in
some cases in acquired melanocytic nevi and con-
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
In addition to the global features already men-
tioned, the local features (dermoscopic structures
are important to evaluate melanocytic lesions
Because computer hardware has become user-
friendly 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.74Digital images offer
the possibility of computer storage and retrieval of
dermoscopic images and patient data.48,75-78Some
systems even offer the potential of ‘‘computer-
assisted diagnosis.’’79-94Because diagnostic accuracy
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, tele-
dermoscopy 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 in-
frastructure becomes available to almost everyone,
and the exchange is now easy to perform. Recent
studies were able to show the feasibility and impor-
tance of teledermoscopy.95-98This was recently used
in a Consensus Netmeeting on Dermoscopy held in
Rome during the first World57,69Congress on Der-
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
1. Rigel DS, Friedman RJ, Kopf AW. The incidence of malignant
melanoma in the United States: Issues as we approach the
21st century. J Am Acad Dermatol 1996;34:839-47.
2. Rigel DS, Friedman RJ, Kopf AW. Lifetime risk for development
of skin cancer in the U.S. population: current estimate is now 1
in 5. J Am Acad Dermatol 1996;35:1012-3.
3. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics,
1999. CA Cancer J Clin 1999;49:8-31.
4. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics,
1998. CA Cancer J Clin 1998;48:6-29.
5. Rigel DS, Carucci JA. Malignant melanoma: prevention, early
detection, and treatment in the 21st century. CA Cancer J Clin
6. Burton RC. Malignant melanoma in the year 2000. CA Cancer
J Clin 2000;50:209-13.
7. Rigel DS. Malignant melanoma: perspectives on incidence and
its effects on awareness, diagnosis, and treatment. CA Cancer
J Clin 1996;46:195-8.
8. Pehamberger H, Binder M, Steiner A, Wolff K. In vivo
epiluminescence microscopy: improvement of early diagnosis
of melanoma. J Invest Dermatol 1993;100:356S-62S.
9. Soyer HP, Argenziano G, Chimenti S, Ruocco V. Dermoscopy of
pigmented skin lesions. Eur J Dermatol 2001;11:270-6.
10. Soyer HP, Argenziano G, Talamini R, Chimenti S. Is dermoscopy
useful for the diagnosis of melanoma? Arch Dermatol
11. Stolz W, Braun-Falco O, Bilek P, Landthaler M, Burgdorf WHC,
Cognetta AB. Color alas of drmatoscopy. 2nd ed. Berlin:
Blackwell Wissenschafts-Verlag; 2002.
12. Mayer J. Systematic review of the diagnostic accuracy of
dermatoscopy in detecting malignant melanoma. Med J Aust
13. Menzies SW, Crotty KA, Ingvar C, McCarthy WH. An atlas of
surface microscopy of pigmented skin lesions. Sydney:
McGraw-Hill Book Company; 2003.
J AM ACAD DERMATOL
118 Braun et al
14. Binder M, Schwarz M, Winkler A, Steiner A, Kaider A, Wolff K,
et al. Epiluminescence microscopy. A useful tool for the di-
agnosis of pigmented skin lesions for formally trained
dermatologists. Arch Dermatol 1995;131:286-91.
15. Binder M, Puespoeck-Schwarz M, Steiner A, Kittler H, Muellner
M, Wolff K, et al. Epiluminescence microscopy of small
pigmented skin lesions: short-term formal training improves
the diagnostic performance of dermatologists. J Am Acad
16. Westerhoff K, McCarthy WH, Menzies SW. Increase in the
sensitivity for melanoma diagnosis by primary care physicians
using skin surface microscopy. Br J Dermatol 2000;143:
17. Bafounta ML, Beauchet A, Aegerter P, Saiag P. Is dermoscopy
(epiluminescence microscopy) useful for the diagnosis of
melanoma? Results of a meta-analysis using techniques
adapted to the evaluation of diagnostic tests. Arch Dermatol
18. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic
accuracy of dermoscopy. Lancet Oncol 2002;3:159-65.
19. Gilje O, O’Leary PA, Baldes EY. Capillary microscopic examina-
tion in skin siease. Arch Dermatol 1958;68:136-45.
20. Diepgen P. Geschichte der Medizin. Berlin: De Gruyter; 1965.
21. Unna P. Die Diaskopie der Hautkrankheiten. Berl Klin Wochen
22. Saphier J. Die Dermatoskopie. I. Mitteilung. Arch Dermatol
23. Saphier J. Die Dermatoskopie. II. Mitteilung. Arch Dermatol
24. Saphier J. Die Dermatoskopie. IV. Mitteilung. Arch Dermatol
25. Saphier J. Die Dermatoskopie. III. Mitteilung. Arch Dermatol
26. Goldman L. Some investigative studies of pigmented nevi
with cutaneous microscopy. J Invest Dermatol 1951;16:407-26.
27. Goldman L. Clinical studies in microscopy of the skin at
moderate magnification. Arch Dermatol 1957;75:345-60.
28. Goldman L. A simple portable skin microscope for surface
microscopy. Arch Dermatol 1958;78:246-7.
29. Goldman L. Direct skin microscopy as an aid in the early
diagnosis of precancer and cancer of the skin in the elderly.
J Am Geriatr Soc 1980;28:337-40.
30. MacKie RM. An aid to the preoperative assessment of
pigmented lesions of the skin. Br J Dermatol 1971;85:232-8.
31. Bahmer FA, Fritsch P, Kreusch J, Pehamberger H, Rohrer C,
Schindera I, et al. Diagnostische Kriterien in der Auflichtsmik-
roskopie. Konsensus-Treffen der Arbeitsgruppe Analytische
Morphologie der Arbeitsgemeinschaft Dermatologische For-
32. Argenziano G, Soyer HP, Chimenti S, Talamini R, Corona R, Sera
F, et al. Dermoscopy of pigmented skin lesions: results of
a consensus meeting via the Internet. J Am Acad Dermatol
33. Anderson RR, Parrish JA. The optics of human skin. J Invest
34. Braun RP, Saurat JH, Krischer J. Diagnostic pearl: unmagnified
diascopy for large pigmented lesions reveals features similar
to those of epiluminescence microscopy. J Am Acad Dermatol
35. Bahmer FA, Rohrer C. Rapid and simple macrophotography of
the skin. Br J Dermatol 1986;114:135-6.
36. Argenziano G, Soyer HP, De Giorgi V, Piccolo D, Carli P, Delfino
M, et al. Dermoscopy: a tutorial. 1st ed. Milano: EDRA; 2000.
37. Kenet RO, Kang S, Kenet BJ, Fitzpatrick TB, Sober AJ, Barnhill
RL. Clinical diagnosis of pigmented lesions using digital
epiluminescence microscopy. Grading protocol and atlas.
Arch Dermatol 1993;129:157-74.
38. Reisfeld PL. Blue in the skin. J Am Acad Dermatol 2000;42:
39. Pehamberger H, Steiner A, Wolff K. In vivo epiluminescence
microscopy of pigmented skin lesions. I. Pattern analysis of
pigmented skin lesions. J Am Acad Dermatol 1987;17:571-83.
40. Krischer J, Skaria A, Guillod J, Lemonnier E, Salomon D, Braun
R, et al. Epiluminescent light microscopy of melanocytic
41. Massi D, De Giorgi V, Soyer HP. Histopathologic correlates of
dermoscopic criteria. Dermatol Clin 2001;19:259-68.
42. Soyer HP, Kenet RO, Wolf IH, Kenet BJ, Cerroni L. Clinicopath-
ological correlation of pigmented skin lesions using dermo-
scopy. Eur J Dermatol 2000;10:22-8.
43. Yadav S, Vossaert KA, Kopf AW, Silverman M, Grin-Jorgensen
C. Histopathologic correlates of structures seen on dermo-
scopy (epiluminescence microscopy). Am J Dermatopathol
44. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Sammarco E,
Delfino M. Epiluminescence microscopy for the diagnosis of
doubtful melanocytic skin lesions. Comparison of the ABCD
rule of dermatoscopy and a new 7-point checklist based on
pattern analysis. Arch Dermatol 1998;134:1563-70.
45. Nachbar F, Stolz W, Merkle T, Cognetta AB, Vogt T, Landthaler
M, et al. The ABCD rule of dermatoscopy: high prospective
value in the diagnosis of doubtful melanocytic skin lesions.
J Am Acad Dermatol 1994;30:551-9.
46. Soyer HP, Smolle J, Ho ¨dl S, Pachernegg H, Kerl H. Surface
microscopy: a new approach to the diagnosis of cutaneous
pigmented tumors. Am J Dermatopathol 1989;11:1-10.
47. Guillod JF, Skaria AM, Salomon D, Saurat JH. Epiluminescence
videomicroscopy: black dots and brown globules revisited by
stripping the stratum corneum. J Am Acad Dermatol
48. Kittler H, Seltenheim M, Dawid M, Pehamberger H, Wolff K,
Binder M. Frequency and characteristics of enlarging common
melanocytic nevi. Arch Dermatol 2000;136:316-20.
49. Menzies SW, Ingvar C, McCarthy WH. A sensitivity and
specificity analysis of the surface microscopy features of
invasive melanoma. Melanoma Res 1996;6:55-62.
50. Menzies SW, Crotty KA, McCarthy WH. The morphologic
criteria of the pseudopod in surface microscopy. Arch
51. Argenziano G, Scalvenzi M, Staibano S, Brunetti B, Piccolo D,
Delfino M, et al. Dermatoscopic pitfalls in differentiating
pigmented Spitz naevi from cutaneous melanomas. Br J
52. Argenziano G, Soyer HP, Ferrara G, Piccolo D, Hofmann-
Wellenhof R, Peris K, et al. Superficial black network: an
additional dermoscopic clue for the diagnosis of pigmented
spindle and/or epithelioid cell nevus. Dermatology 2001;
53. Steiner A, Pehamberger H, Binder M, Wolff K. Pigmented Spitz
nevi: improvement of the diagnostic accuracy by epilumines-
cence microscopy. J Am Acad Dermatol 1992;27:697-701.
54. Massi D, De Giorgi V, Carli P, Santucci M. Diagnostic
significance of the blue hue in dermoscopy of melanocytic
lesions: a dermoscopic-pathologic study. Am J Dermatopathol
55. Kreusch J, Rassner G. Auflichtmikroskopie pigmentierter
Hauttumoren. Stuttgart: Thieme; 1991.
56. Kreusch J, Rassner G, Trahn C, Pietsch-Breitfeld B, Henke D,
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al 119
morphological features to identify malignant melanoma.
Pigment Cell Res 1992:295-8.
57. Kreusch J, Koch F. Auflichtmikroskopische Charakterisierung
von Gefassmustern in Hauttumoren. Hautarzt 1996;47:264-72.
58. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Delfino M.
Epiluminescence microscopy: criteria of cutaneous melanoma
progression. J Am Acad Dermatol 1997;37:68-74.
59. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Delfino M.
Clinical and dermatoscopic criteria for the preoperative
evaluation of cutaneous melanoma thickness. J Am Acad
60. Argenyi ZB. Dermoscopy (epiluminescence microscopy) of
pigmented skin lesions. Current status and evolving trends.
Dermatol Clin 1997;15:79-95.
61. Carli P, De Giorgi V, Soyer HP, Stante M, Mannone F, Giannotti
B. Dermatoscopy in the diagnosis of pigmented skin lesions:
a new semiology for the dermatologist. J Eur Acad Dermatol
62. Steiner A, Pehamberger H, Wolff K. In vivo epiluminescence
microscopy of pigmented skin lesions. II. Diagnosis of small
pigmented skin lesions and early detection of malignant
melanoma. J Am Acad Dermatol 1987;17:584-91.
63. Braun RP, Rabinovitz H, Krischer J, Kreusch J, Oliviero M, Naldi
L, et al. Dermoscopy of pigmented seborrheic keratosis. Arch
64. Provost N, Kopf AW, Rabinovitz HS, Oliviero MC, Toussaint S,
Kamino HH. Globulelike dermoscopic structures in pigmented
seborrheic keratosis. Arch Dermatol 1997;133:540-1.
65. Braun RP, Rabinovitz H, Oliviero M, Kopf AW, Saurat JH,
Thomas L. Dermatoscopy of pigmented lesions. Ann Dermatol
66. Schiffner R, Schiffner-Rohe J, Vogt T, Landthaler M, Wlotzke U,
Cognetta AB, et al. Improvement of early recognition of
lentigo maligna using dermatoscopy. J Am Acad Dermatol
67. Menzies SW, Westerhoff K, Rabinovitz H, Kopf AW, McCarthy
WH, Katz B. Surface microscopy of pigmented basal cell
carcinoma. Arch Dermatol 2000;136:1012-6.
68. Soyer HP, Argenziano G, Ruocco V, Chimenti S. Dermoscopy of
pigmented skin lesions (Part II). Eur J Dermatol 2001;11:
69. Wang SQ, Katz B, Rabinovitz H, Kopf AW, Oliviero M. Lessons
on dermoscopy #4. Poorly defined pigmented lesion. Di-
agnosis: pigmented BCC. Dermatol Surg 2000;26:605-6.
70. Stolz W, Riemann A, Cognetta AB, Pillet L, Abmayr W, Ho ¨lzel D,
et al. ABCD rule of Dermatoscopy: a new practical method for
early recognition of malignant melanoma. Eur J Dermatol
71. Braun RP, Rabinovitz H, Oliviero M, Kopf AW, Saurat JH.
Pattern analysis: a two step procedure for the dermoscopic
diagnosis of melanoma. Clin Dermatol 2002;20:236-9.
72. Saida T, Oguchi S, Ishihara Y. In vivo observation of magnified
features of pigmented lesions on volar skin using video
macroscope. Usefulness of epiluminescence techniques in
clinical diagnosis. Arch Dermatol 1995;131:298-304.
73. Cognetta AB Jr, Stolz W, Katz B, Tullos J, Gossain S. Dermato-
scopy of lentigo maligna. Dermatol Clin 2001;19:307-18.
74. Kittler H, Seltenheim M, Pehamberger H, Wolff K, Binder M.
Diagnostic informativeness of compressed digital epilumines-
cence microscopy images of pigmented skin lesions com-
pared with photographs. Melanoma Res 1998;8:255-60.
75. Braun RP, Lemonnier E, Guillod J, Skaria A, Salomon D, Saurat
JH. Two types of pattern modification detected on the follow-
up of benign melanocytic skin lesions by digitized epilumi-
nescence microscopy. Melanoma Res 1998;8:431-7.
76. Kittler H, Pehamberger H, Wolff K, Binder M. Follow-up of
melanocytic skin lesions with digital epiluminescence micros-
copy: patterns of modifications observed in early melanoma,
atypical nevi, and common nevi. J Am Acad Dermatol
77. Menzies SW, Gutenev A, Avramidis M, Batrac A, McCarthy WH.
changing melanocytic lesions. Arch Dermatol 2001;137:1583-9.
78. Stolz W, Schiffner R, Pillet L, Vogt T, Harms H, Schindewolf T,
et al. Improvement of monitoring of melanocytic skin lesions
with the use of a computerized acquisition and surveillance
unit with a skin surface microscopic television camera. J Am
Acad Dermatol 1996;35:202-7.
79. Binder M, Steiner A, Schwarz M, Knollmayer S, Wolff K,
Pehamberger H. Application of an artificial neural network in
epiluminescence microscopy pattern analysis of pigmented
skin lesions: a pilot study. Br J Dermatol 1994;130:460-5.
80. Binder M, Kittler H, Seeber A, Steiner A, Pehamberger H, Wolff
K. Epiluminescence microscopy-based classification of pig-
mented skin lesions using computerized image analysis and
an artificial neural network. Melanoma Res 1998;8:261-6.
81. Binder M, Kittler H, Dreiseitl S, Ganster H, Wolff K, Peham-
berger H. Computer-aided epiluminescence microscopy of
pigmented skin lesions: the value of clinical data for the
classification process. Melanoma Res 2000;10:556-61.
82. Day GR, Barbour RH. Automated melanoma diagnosis: where
are we at? Skin Res Technol 2000;6:1-5.
83. Debeir O, Decaestecker C, Pasteels JL, Salmon I, Kiss R, Van
Ham P. Computer-assisted analysis of epiluminescence mi-
croscopy images of pigmented skin lesions. Cytometry
84. Elbaum M, Kopf AW, Rabinovitz HS, Langley RG, Kamino H,
Mihm MC Jr, et al. Automatic differentiation of melanoma
from melanocytic nevi with multispectral digital dermoscopy:
a feasibility study. J Am Acad Dermatol 2001;44:207-18.
85. Fleming MG, Steger C, Zhang J, Gao J, Cognetta AB, Pollak I,
et al. Techniques for a structural analysis of dermatoscopic
imagery. Comput Med Imaging Graph 1998;22:375-89.
86. Gutenev A, Skladnev VN, Varvel D. Acquisition-time image
quality control in digital dermatoscopy of skin lesions. Comput
Med Imaging Graph 2001;25:495-9.
87. Gutkowicz-Krusin D, Elbaum M, Jacobs A, Keem S, Kopf AW,
Kamino H, et al. Precision of automatic measurements of
pigmented skin lesion parameters with a MelaFind(TM) mul-
tispectral digital dermoscope. Melanoma Res 2000;10:563-70.
88. Menzies SW. Automated epiluminescence microscopy: human
vs machine in the diagnosis of melanoma. Arch Dermatol
89. Moncrieff M, Cotton S, Claridge E, Hall P. Spectrophotometric
intracutaneous analysis: a new technique for imaging pig-
mented skin lesions. Br J Dermatol 2002;146:448-57.
90. Murali A, Stoecker WV, Moss RH. Detection of solid pigment in
dermatoscopy images using texture analysis. Skin Res Technol
91. Rubegni P, Ferrari A, Cevenini G, Piccolo D, Burroni M, Perotti
R, et al. Differentiation between pigmented Spitz naevus and
melanoma by digital dermoscopy and stepwise logistic
discriminant analysis. Melanoma Res 2001;11:37-44.
92. Schmid P. Segmentation of digitized dermatoscopic images
by two-dimensional color clustering. IEEE Trans Med Imaging
93. Smolle J. Computer recognition of skin structures using
94. Stoecker WV, Moss RH. Digital imaging in dermatology.
Comput Med Imaging Graph 1992;16:145-50.
J AM ACAD DERMATOL
120 Braun et al
95. Braun RP, Meier M, Pelloni F, Ramelet AA, Schilling M,
Tapernoux B, et al. Teledermatoscopy in Switzerland: a pre-
liminary evaluation. J Am Acad Dermatol 2000;42:770-5.
96. Piccolo D, Smolle J, Argenziano G, Wolf IH, Braun R, Cerroni L,
et al. Teledermoscopy—results of a multicentre study on 43
pigmented skin lesions. J Telemed Telecare 2000;6:132-7.
97. Piccolo D, Smolle J, Wolf IH, Peris K, Hofmann-Wellenhof R,
Dell’Eva G, et al. Face-to-face diagnosis vs telediagnosis of
pigmented skin tumors: a teledermoscopic study. Arch Der-
98. Provost N, Kopf AW, Rabinovitz HS, Stolz W, DeDavid M, Wasti
Q, et al. Comparison of conventional photographs and tele-
phonically transmitted compressed digitized images of mela-
nomas and dysplastic nevi. Dermatology 1998;196:299-304.
1. Argenziano G, Soyer HP, De Giorgi V, Piccolo D, Carli P, et al.
Dermoscopy: A tutorial. 1st ed. Milan: EDRA; 2000.
2. Menzies SW, Crotty KA, Ingvar C, McCarthy WH. An atlas of
surface microscopy of pigmented lesions. Sydney: McGraw-Hill
3. Stolz W, Braun-Falco O, Bilek P, Landthaler M, Burgdorf WHC,
Cognetta AB. Color atlas of dermatoscopy. 2nd ed. Berlin:
Blackwell Wessenschafts-Verlag; 2002.
4. Soyer HP, Argenziano G, Chimenti S, Rabinovitz HS, Stolz W,
Kopf AW, et al. Dermoscopy of pigmented lesions. Milan: EDRA;
5. Rabinovitz HS, Cognetta AB. Dermatologic clinics. Philadelphia
(PA): WB Saunders; 2001.
6. Johr R, Soyer HP, Argenziano G, Hofmann-Wellenhof R,
Scalvenzi M. Dermoscopy: The essentials. London: Mosby; 2004.
8. Marghoob AA, Braun RP, Kopf AW. Atlas of dermoscopy.
London: Taylor & Francis; 2005.
9. Malvehy J, Puig S. Principles of dermoscopy. Barcelona: CEGE
J AM ACAD DERMATOL
VOLUME 52, NUMBER 1
Braun et al121