Dermoscopy The Essentials - Soyer - 2nd Ed - 2012

DERMOSCOPY
The Essentials
ERRNVPHGLFRVRUJ
Commissioning Editor: Russell Gabbedy
Development Editor: John Leonard
Project Manager: Cheryl Brant
Design: Kirsteen Wright
Marketing Manager(s) (UK/USA): Gaynor Jones/Helena Mutak
DERMOSCOPY
The Essentials SECOND EDITION
H. Peter Soyer, MD, FACD

Professor and Chair
Dermatology Research Centre
The University of Queensland
School of Medicine
Princess Alexandra Hospital
Brisbane
Australia
Giuseppe Argenziano, MD
Professor of Dermatology
Dermatology Unit
Medical Department
Arcispedale Santa Maria Nuova
Reggio Emilia
Italy
Rainer Hofmann-Wellenhof, MD
Department of Dermatology
Medical University of Graz
Graz
Austria
Iris Zalaudek, MD
Department of Dermatology
Medical University of Graz
Graz
Austria
ERRNVPHGLFRVRUJ
# 2012, Elsevier Limited. All rights reserved.
First edition 2004

Second edition 2012
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ISBN: 978-0-7234-3592-1
Saunders
British Library Cataloguing in Publication Data
Dermoscopy : the essentials. – 2nd ed.

1. Skin–Cancer–Diagnosis.
I. Soyer, H. Peter.
616.90 94770754-dc22
ISBN-13: 9780723435921
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contents
Foreword vii
Preface to the First Edition ix
Preface to the Second Edition xi
Acknowledgements xiii
1 INTRODUCTION – THE 3-POINT CHECKLIST 1

Technique 1
The 3-point checklist 1
2 PATTERN ANALYSIS 33
Four global dermoscopic patterns for melanocytic nevi 33
Diagnosis of melanoma using five melanoma-specific criteria 78
Diagnosis of facial melanoma using four site-specific melanoma-specific criteria 93
Four patterns for acral melanocytic lesions 100
Six criteria for diagnosing non-melanocytic lesions 107
3 COMMON CLINICAL SCENARIOS 139

Introduction 139
Pediatric scenario 139
Black lesions 144
Inkspot lentigo 148
Blue lesions 152
Reticular lesions 156
Spitzoid lesions 160
Special nevi 164
Multiple Clark (dysplastic) nevi 168
Follow-up of melanocytic lesions 172
Lesions with regression 176
Flat lesions on the face 180
Nodular lesions on the face 184
Acral lesions 188
Pigmented lesions of the nails 192
Mucosal lesions 196
Differential diagnostic value of blood vessels 200
Amelanotic and partially pigmented melanoma 207
Dermoscopy tests 211
Further reading 217

Index 223
v
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Foreword
As a big fan of the first edition of Dermoscopy-The makes learning dermoscopy easy and intuitive. The
Essentials, I am honored to have the opportunity to accompanying brief, conversational and occasionally
write this brief forward to the new and improved light hearted narrative, makes for an easy and
second edition. I congratulate the authors for whom memorable read. Whether you are a dermoscopy
this project is an obvious labor of love. They have novice reading through the book from beginning to
succeeded in making a great book even better. I also end, or a more experienced dermoscopist jumping
congratulate you, the reader, for having settled upon from section to section and comparing your
such an intuitive and effective primer in your quest to assessment with those of the authors, the book is an
master dermoscopy. absolute joy.
At the time of its original printing in 2004, For the reader who has already accomplished some
Dermoscopy-The Essentials had relatively little mastery of dermoscopy, I know you will derive great
competition and, in the case of the United States pleasure from the quality of the enclosed images and
audience, a very limited market. In the intervening the insights of the authors. For the novice, I have to
years interest in dermoscopy has grown considerably. warn you that reading this book is the first step along
Diffusion of the use of dermoscopy into clinical a path to dependency. Once you have invested the
practice in the United States continues to lag time to become proficient in the use of dermoscopy,
somewhat behind that of Europe, but nevertheless it is you will no longer be satisfied with simple visual
now quite robust. Worldwide, there has been a rapid inspection. Your sense of both cognitive gratification
increase in dermoscopy associated publications both and clinical confidence will increasingly depend on
as it relates to original observations and teaching the application of this very simple yet so elegant
materials, but in this now more crowded landscape, technique.
Dermoscopy-The Essentials continues to stand out as an
especially valuable tutorial and reference.
I commend the authors of this volume for their use
of such a simple yet elegant and effective format. The Allan C. Halpern, MD MSc
traffic light visual tool coupled with the check box Chief, Dermatology Service
characterization of a large collection of some of the Memorial Sloan Kettering Cancer Center
best clinical and dermoscopic images in the literature, New York, New York USA
vii
Preface to the First Edition
The authors of this book are on a quest. For years we lesions, green for low-risk lesions and orange for the
have been lecturing, creating articles, CDs and books gray-zone lesions. The associations between what you
with the goal of making dermoscopy, dermatoscopy, see with dermoscopy and the traffic light colors will
epiluminescence microscopy, ELM, skin surface sink into the recesses of your mind and come into play
microscopy, or whatever you choose to call the when you see similar dermoscopic criteria or patterns
technique, the standard of care for all dermatologists on your patients. You have to learn the basics;
and others who see patients with pigmented skin however, intuition and ‘gut’ feelings come into play
lesions. There are wonderful works already written in on a regular basis. Never ignore instinctive
the standard fashion that promote dermoscopy, yet in impressions.
some way they have not lit a fire in us all to joyfully We worked very well together as a team but it was
and relatively effortlessly learn a technique that spares not always easy, especially since the authors live on
tissue and saves lives. different continents and we face the typical trials and
If there are books that can teach languages such as tribulations of the human experience. However, we
German or Italian in ‘10 minutes a day’ why not create never lost sight of our goal and egos did not take hold.
a dermoscopy book that is ‘short and sweet’, ‘101’, fun This book is a work of love from doctors who are true
and easy to go through? The aim is to include images believers in a technique that is essential for our
that cover everything that is out there, not only in a patients. People’s fathers, mothers, sons, daughters,
university clinic but also in private practice, and with grandparents, aunts, and uncles entrust us with their
facts that are the essentials and more! health, their lives! We have the responsibility to be the
This is not a classic medical textbook and that is best that we can be to prevent the pain and suffering
intentional. For example, the ‘traffic lights’ are a tool that goes along with the most insidious of enemies,
for the busy practitioner to use to rapidly review the melanoma. Let dermoscopy be like the seat belt of
book over and over again, because one aspect of your car. You should never leave home without it.
mastering dermoscopy is the internalization of the
The Authors
basic principles. Look at the images, then look at the
colors of the traffic lights. Red indicates high-risk
ix
Preface to the Second Edition
How time flies! It’s hard to believe that the first edition while to refine and update the content and, if relevant,
of Dermoscopy: The Essentials is now already seven years the illustrations. We specifically focused on this
old and so it is time for us to revamp our book; a task second goal with this new edition and have substituted
greeted with both enthusiasm and eagerness by our nearly 50% of the dermoscopic and clinical images
new author team. For this second edition we welcome and have unified all the annotations.
Dr Iris Zalaudek and we say goodbye to Drs Johr and We are especially indebted to the Elsevier Editorial
Scalvenzi. However, where we may be new in terms of Team, John Leonard and Russell Gabbedy, for their
the project at hand, we are old as colleagues and peers, highly professional support of our work and for being
having known each other for over 10 years (up to so flexible in the many small aspects intrinsic to
nearly 20 years in some cases), and having been publishing a book.
through many highs and lows together. Even though As with the first edition we consign our book to all
great distances separate us physically, through the use those interested in the science and art of dermoscopy
of modern technology and our own developed and hope that we contribute to the lofty goal of
strategies and procedures we continue to work together eradicating melanoma.
and collaborate, negating the physical distance from
each other to an impression of merely being next-door
to one another. In this modern age the physical H. Peter Soyer, Brisbane, Australia
distance of thousands of kilometers and eight to nine Giuseppe Argenziano, Reggio Emilia, Italy
different time zones are obstacles no longer. Rainer Hofmann-Wellenhof, Graz, Austria
The theory for a second edition is usually to Iris Zalaudek, Graz, Austria & Reggio Emilia, Italy
maintain the concept and design in general terms, 2011
KEY TO TRAFFIC LIGHT SYMBOLS
High risk lesions
Moderate risk lesions
Low risk lesions
xi
Acknowledgements
To my Oz-based team, Zoja and Niko, for both To my teacher in dermoscopy and to my friends in the
their support and welcome distraction from field of dermoscopy. Special thanks go to my wife
my work. Andrea and my children Elisabeth, Paul, Martin and
H. Peter Soyer Georg, who have given me the strength to joyfully
work on the book.
To my mentor, my best friends and the love of my life, Rainer Hofmann-Wellenhof
all of whom are with me in this book. To my children,
Silvia and Gabriele, who are the most precious part To my "dermoscopy" family for their friendship, to
of my life. my parents Ilse and Gunter, my sister Karin and my
Giuseppe Argenziano niece Lilith for their love, and for the one representing
both families in my life.
Iris Zalaudek
xiii
xiv
Introduction: The 3-point
checklist
The short, easy way to avoid missing a melanoma using
1
dermoscopy
Box 1.1 Other names for dermoscopy 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
Dermoscopy is an in vivo noninvasive diagnostic the technique have been developed.
technique that magnifies the skin in such a way that For the novice dermoscopist, the primary goal of
color and structure in the epidermis, dermoepidermal dermoscopy is to determine whether a suspicious
junction, and papillary dermis become visible. This lesion should be biopsied or excised. The bottom line
color and structure cannot be seen with the naked eye. is that no patient should leave the clinic with an
With training and experience, dermoscopy has been undiagnosed melanoma.
shown to significantly increase the clinical diagnosis For the general physician, dermoscopy can be used
of melanocytic, non-melanocytic, benign and to determine whether a suspicious lesion should be
malignant skin lesions, with a 10-27% improvement evaluated by a more experienced clinician.
in the diagnosis of melanoma compared to that Dermoscopy is not just for dermatologists; any
achieved by clinical examination alone. There is, clinician who is interested can master this potentially
however, a learning curve to mastering dermoscopy, life-saving technique.
and it is essential to spend time perfecting it—practice
makes perfect! Triage of suspicious pigmented skin lesions
The 3-point checklist was developed specifically for
novice 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
• dermoscopic asymmetry of color and structure;
that exploit the properties of cross-polarized light
• atypical pigment network; and
(polarized dermoscopy), visualization of deep skin
• blue-white structures (a combination of the
structures can be achieved without the necessity of a
previous categories of blue-white veil and
liquid interface or direct skin contact with the
regression structures).
instrument.
The list of dermoscopy instrumentation is long and Statistical analysis showed that the presence of any
continues to grow and evolve with the development of two of these criteria indicates a high likelihood of
better and more sophisticated handheld instruments melanoma. Using the 3-point checklist, one can
and computer systems. Depending on the budget and have a sensitivity and specificity result comparable
goals for the evaluation and management of patients with other algorithms requiring much more
1
training. In a preliminary study of 231 clinically
DERMOSCOPY - The Essentials
Table 1.1 Definition of dermoscopic criteria for the
equivocal pigmented skin lesions, it was shown
3-point checklist. The presence of two or three
that, after a short introduction of 1-h duration,
criteria is suggestive of a suspicious lesion
six inexperienced dermoscopists were able to
classify 96.3% of melanomas correctly using this
3-Point checklist Definition
method.
This first chapter provides 60 examples of benign 1. Asymmetry Asymmetry of color and
and malignant pigmented skin lesions to demonstrate structure in one or two
how the 3-point checklist works and the practical perpendicular axes
value of this new and simplified diagnostic algorithm. 2. Atypical network Pigment network with
The 3-point checklist was designed to be used as a irregular holes and thick lines
screening method. The sensitivity is much higher than 3. Blue-white structures Any type of blue and/or white
the specificity to ensure that melanomas are not color
misdiagnosed. We recommend that all lesions with a
positive test (3-point checklist score of 2 or 3) are
excised.
2
1
Introduction: The 3-point checklist

Checklist
Asymmetry
Atypical network
Blue-white structures
* Total score 3
*
*
Figure 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
network (circle), and blue-white structures (asterisks).
Checklist
Asymmetry
Atypical network
Total score 0
Figure 2 Nevus
In contrast to Figure 1, none of the features of the 3-point checklist is 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
Checklist
Asymmetry
Atypical network
Total score 1
Figure 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
Total score 2
Figure 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
Asymmetry
Atypical network
Total score 3
Figure 5 Melanoma
The color and structure in the lower half is not a mirror image of the upper half; therefore, there is
asymmetry. 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
Total score 2
Figure 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 chrysalis-
like structures) (arrows) representing a variation on the theme of blue-white structures.
5
Checklist
Asymmetry
Atypical network
Total score 1
Figure 7 Seborrheic keratosis

This seborrheic keratosis demonstrates a great deal of asymmetry of color and structure, but the other
two criteria needed to diagnose melanoma are absent. If the multiple milia-like cysts (arrows) diagnostic
of seborrheic keratosis cannot be recognized, excise the lesion.
Checklist
Asymmetry
Atypical network
Total score 1
Figure 8 Nevus
Some melanomas are featureless, so beware! The color and structure in the right half of the lesion is not a
mirror image of the left half. The presence of irregular black dots in the left upper corner (circle) add to the
asymmetry. Pigment network and blue-white structures are not seen.
6
1

Checklist
Asymmetry
Atypical network
Total score 0
Figure 9 Nevus
If in doubt, cut it out! With practice, fewer lesions that look like this will be excised. This is highly
symmetrical, and there is a great example of a regular pigment network in this banal nevus. Do not be
fooled by the dark central color—it is not always a sign of malignancy. No blue-white structures are seen.
Checklist
Asymmetry
Atypical network
Total score 3
Figure 10 Melanoma
This lesion is a straightforward case of melanoma. The diagnostic criteria are striking, obvious asymmetry
of color and structure, a markedly atypical pigment network (arrows), and blue-white structures (circle).
7
Checklist
Asymmetry
Atypical network
Total score 1
Figure 11 Nevus
The clinical ABCDs could lead you astray with this banal nevus. There is asymmetry, but there is also a
typical pigment network and blue-white structures are absent.
Checklist
Asymmetry
Atypical network
Total score 2
*
*
*
*
Figure 12 Melanoma
The yellowish globules seen here are not the multiple milia-like cysts of a seborrheic keratosis. They are
the ostia of appendages as seen only on head and neck lesions (arrows). There is slight asymmetry of
color and structure, and no pigment network is observed; however, blue-white structures are seen
throughout the lesion (asterisks).
8
1

Checklist
Asymmetry
Atypical network
Total score 3
*
*
Figure 13 Melanoma
Clinicians might think that this lesion is nothing to worry about until they examine it with dermoscopy.
There is asymmetry of color and structure, an atypical pigment network and blue-white structures
(asterisks) cover part of the lesion.
Checklist
Asymmetry
Atypical network
* Blue-white structures
* Total score 2
*
*
Figure 14 Melanoma
The extensive blue-white structures (asterisks) are the first clue to the seriousness of this lesion.
Particularly color is clearly asymmetrical. A pigment network is absent, and there are well-developed
blue-white structures.
9
Checklist
Asymmetry
Atypical network
Total score 2
Figure 15 Basal cell carcinoma

This lesion demonstrates nicely the in-focus arborizing vessels typical for a nodular basal cell carcinoma.
Two positive features of the checklist are clearly present—asymmetry and blue-white structures (arrows).
There is no pigment network.
Checklist
Asymmetry
Atypical network
Total score 3
Figure 16 Melanoma
Asymmetry is unmistakably present in this lesion, but whether the pigment network is atypical in the right
upper corner (arrow) is debatable. Blue-white structures (circle) are clearly seen. There is no doubt that it
should be excised.
10
1

Checklist
Asymmetry
Atypical network
Total score 2

This lesion is so bizarre looking that you should excise it as soon as possible. There is asymmetry of color
and structure, and delicate blue-white structures are found throughout. No pigment network is seen.
Because two of the three criteria from the 3-point checklist are present, the lesion should be excised.
Checklist
Asymmetry
Atypical network
* * Total score 2
Figure 18 Melanoma
This lesion is clearly not benign. Is it, however, a basal cell carcinoma or melanoma? Once again, there is
significant asymmetry of color and structure with prominent blue-white structures (asterisks). It is difficult
to decide whether a pigment network is present or not (arrows).
11
Checklist
Asymmetry
Atypical network
Total score 1
Figure 19 Nevus
This stereotypical benign nevus is commonly seen when performing dermoscopy. The blotch of dark
brown color is not significant. Although there is slight asymmetry of color and structure, the lesion is
characterized by a typical pigment network and no clear-cut blue-white structures are seen.
Checklist
Asymmetry
Atypical network
Total score 2
*
*
*
Figure 20 Nevus
The pattern of criteria shown here is most often seen with a Spitz nevus, but the differential diagnosis should
include Clark (dysplastic) nevus and melanoma. There is slight asymmetry of color and structure. A pigment
network is absent, with blue-white structures (asterisks). The checklist will not work for all lesions, and it is
important to take into account the history and age of the patient when deciding what to do.
12
1

Checklist
Asymmetry
Atypical network
Total score 3
* *
*
Figure 21 Nevus
Another Spitz nevus-like pattern is demonstrated in this lesion, this time with hints of an atypical pigment
network (circle) and blue-white structures (asterisks).
Checklist
Asymmetry
* Atypical network
Total score 2
*
*
*
Figure 22 Melanoma
This banal clinical lesion has a strikingly worrisome dermoscopic appearance, with asymmetry of color
and structure. No pigment network is present, but blue-white structures are seen throughout the lesion
(asterisks).
13
Checklist
Asymmetry
Atypical network
Total score 1
Figure 23 Nevus
This lesion is benign. Compare it with the other lesions shown in this chapter with more obvious
asymmetry of color and structure, an atypical pigment network, and blue-white structures. There is slight
asymmetry of color and structure, although 100% symmetry is never found in nature. No pigment network
or blue-white structures are seen.
Checklist
Asymmetry
Atypical network
Total score 2
*
*
*
Figure 24 Nevus
Two criteria of the 3-point checklist are present in this lesion, which should therefore be excised. There is
slight asymmetry and an atypical pigment network covering the left part of the lesion (asterisks).
14
1

Checklist
Asymmetry
Atypical network
Total score 3
*
*
Figure 25 Melanoma
This is a clear-cut melanoma because of the striking asymmetry of color and structure, and the presence
of diffuse blue-white structures (asterisks). An atypical pigment network can be discerned in the right part
of the lesion (circle).
Checklist
Asymmetry
Atypical network
* * Total score 2
*
*

There is no doubt that this pigmented neoplasm displays two criteria of the 3-point checklist. Note the
striking asymmetry. No pigment network is seen, but several blue-white structures are present (asterisks).
15
Checklist
Asymmetry
Atypical network
Total score 3
Figure 27 Melanoma
All three checklist criteria are seen in this lesion. There is significant asymmetry of color and structure with
a well-developed atypical pigment network (arrows). In the right lower part of the lesion, a blue-white
structure can be discerned (circle).
Checklist
Asymmetry
Atypical network
Total score 2
Figure 28 Melanoma
Significant asymmetry of color and structure is created by blue-white structures (arrows), which occupy
most of the lesion. An atypical pigment network is not seen.
16
1

Checklist
Asymmetry
Atypical network
Total score 1
Figure 29 Nevus
Only one of the checklist criteria is present in this lesion, so this lesion is benign. The lower half of the
lesion does not mirror the upper half, thereby displaying subtle asymmetry. No pigment network or blue-
white structures are seen.
Checklist
Asymmetry
Atypical network
Total score 1
Figure 30 Nevus
The presence of a single criterion from the checklist is usually not sufficient to diagnose malignancy. Note
the asymmetry of color and structure—the left side of the lesion is not a mirror image of the right side. An
atypical pigment network and blue-white structures are absent.
17
Checklist
Asymmetry
Atypical network
Total score 1
*
*
Figure 31 Nevus
This is a difficult lesion to interpret. Although only one criterion of the 3-point checklist is present, the
overall appearance may raise some suspicion that it could be a melanoma. The lesion is symmetrical and
there is no pigment network. In the center, blue-white structures are so slight that they might be difficult to
detect (asterisks).
Checklist
Asymmetry
Atypical network
Total score 3
Figure 32 Melanoma
All criteria of the 3-point checklist are present, underlining the impression that this lesion is a melanoma.
Although the contour is symmetrical, there is asymmetry of color and structure within. A clear-cut
thickened pigment network (arrows) is present, with small foci of blue-white structures (circles) in the
center of the lesion. This early melanoma might go undiagnosed if dermoscopy is not used.
18
1

Checklist
Asymmetry
Atypical network
Total score 3
*
*
*
Figure 33 Melanoma
Once again, all three features of the checklist are clearly present and even a novice dermoscopist should
immediately suspect a melanoma. There is striking asymmetry of color and structure with zones
displaying an atypical pigment network (arrow). There are also clear-cut areas with another variation on
the theme of blue-white structures, namely, peppering (asterisks).
Checklist
Asymmetry
Atypical network
Total score 2

The lower half of this lesion is not a mirror image of the upper half, and the right side is not a mirror image
of the left side; therefore, this is an asymmetrical lesion. No pigment network is identified, but there are
numerous blue-white structures seen throughout (circle). Remember, when two criteria are identified, the
lesion should be excised.
19
Checklist
Asymmetry
Atypical network
Total score 2
*
* *
*
*
Figure 35 Nevus
Despite the significant asymmetry of color and structure, this lesion is benign. There is no hint of a
pigment network, but blue-white structures are present (asterisks). With a score of 2, excise this lesion or
show it to a more experienced dermoscopist.
Checklist
Asymmetry
Atypical network
* Total score 3
Figure 36 Nevus
This is a difficult lesion to diagnose because all three features are very subtle. There is an atypical pigment
network on the left side (arrow) and globules (circle) on the right side; it is therefore an asymmetrical
lesion. Blue-white structures (asterisks) can also be seen throughout.
20
1

Checklist
Asymmetry
Atypical network
Total score 1
Figure 37 Nevus
This is a slightly asymmetrical lesion with a typical pigment network. Do not confuse the multifocal
hypopigmentation (asterisks) with the white color that can be seen in blue-white structures.
Checklist
Asymmetry
Atypical network
Total score 3
Figure 38 Melanoma
Thin melanomas commonly exhibit all three checklist criteria, as demonstrated by this example. There is
asymmetry of color and structure with a few foci (arrows) of an atypical pigment network. In the center, an
area of blue-white structures is also seen (asterisk). The dermoscopic differential diagnosis includes
severely dysplastic nevus and in situ melanoma.
21
Checklist
Asymmetry
Atypical network
* Total score 2
* *
Figure 39 Melanoma
This dark lesion is a cause for concern. Note the shape asymmetry and multiple anastomosing blue-white
structures throughout the lesion (asterisks). With two out of three well-developed criteria present, this
melanoma will not be misdiagnosed if the 3-point checklist is used.
Checklist
Asymmetry
Atypical network
Total score 0
Figure 40 Nevus
There is an obvious lack of striking criteria in this lesion compared to the melanomas already seen in this
chapter. An atypical pigment network and blue-white structures are not seen.
22
1

Checklist
Asymmetry
Atypical network
Total score 3
*
*
Figure 41 Melanoma
This is a clear-cut example of a melanoma with a checklist score of 3. There is striking asymmetry of color
and structure. Several zones exhibit variations of the morphology of an atypical pigment network (arrows).
In paracentral location, blue-white structures can be clearly seen (asterisks). Always concentrate and
focus attention to identify important criteria that might be present in a lesion.
Checklist
Asymmetry
Atypical network
Total score 1
*
*
Figure 42 Nevus
Numerous foci of blue-white structures are seen throughout (asterisks). An atypical pigment network is not
seen. Even though the score is only 1, the dark color and blue-white structures are worrisome. Although it
turned out to be a low-risk nevus, it is better to err on the side of safety and remove these borderline lesions.
With experience, fewer pigmented skin lesions that look like this will be removed.
23
Checklist
Asymmetry
Atypical network
* Total score 1
* *
Figure 43 Nevus
A score of 2 can be achieved for this lesion only if it is considered to be asymmetrical. This image is
similar to Figure 42. The pigment network is typical and is therefore not scored. There are, however,
numerous foci of blue-white structures (asterisks).
Checklist
Asymmetry
Atypical network
Total score 2
*
*
*

Strictly following the 3-point checklist gives this lesion a score of 2. There is slight asymmetry of color and
structure with a few areas of blue-white structures (asterisks). There is no pigment network. With a score of 2,
the novice dermoscopist should remove this lesion, though there will always be exceptions to every rule. With
experience, clinicians will become confident in diagnosing seborrheic keratosis.
24
1

Checklist
Asymmetry
* Atypical network
* Total score 1
Figure 45 Nevus
This lesion has a 3-point checklist score of 1. It is relatively symmetrical and there is no pigment network.
Blue-white structures (asterisks), in this instance only whitish, are clearly visible. This example can be a
potential pitfall for the 3-point checklist because nodular basal cell carcinomas can mimic dermal nevi
dermoscopically, particularly when the vascular structures are not carefully examined.
Checklist
Asymmetry
Atypical network
Total score 1
Figure 46 Nevus
This is another lesion difficult to diagnose for the beginner because its checklist score may be 1 or 2.
Always remember: if a lesion could be high risk, excise it or follow the patient closely. There is slight
asymmetry of dermoscopic structures (globules) but no pigment network. Very subtle whitish areas may
be interpreted as blue-white structures.
25
Checklist
Asymmetry
Atypical network
Total score 1
Figure 47 Nevus
The checklist score for this lesion is only 1, with slight asymmetry of color and structure.
Checklist
Asymmetry
Atypical network
Total score 2
Figure 48 Nevus
This lesion is easy to handle from a management point of view because two of the three checklist criteria
are present, so it should be excised. There is noticeable asymmetry of color and structure, and an atypical
pigment network is found in the left upper half of the lesion. No blue-white structures are seen.
26
1

Checklist
Asymmetry
Atypical network
Total score 2
Figure 49 Nevus
This dermoscopic image is worrisome, showing two of the three checklist criteria. There is asymmetry of
color and structure and foci of an atypical thickened and branched pigment network (arrows). The novice
should excise a lesion with this dermoscopic appearance, although the pathology report might not detect
any high risk.
Checklist
Asymmetry
Atypical network
Total score 1
Figure 50 Nevus
This is a blue nevus for which the checklist score is obviously 1. This lesion is symmetrical, without a
pigment network, but blue-white structures are seen homogeneously throughout the lesion. The
dermoscopic appearance of blue nevi is unique, but always be cautious when making the diagnosis
because rarely nodular melanoma and cutaneous metastatic melanoma mimic a blue nevus.
27
Checklist
Asymmetry
Atypical network
Total score 2
Figure 51 Nevus
Again, the management of this lesion after evaluating it with the 3-point checklist is straightforward. With a
score of 2, this could be a high-risk lesion. There is striking asymmetry of shape and structure. An atypical
pigment network is observed throughout the periphery of the lesion. No blue-white structures are seen.
The discordance between the positive 3-point checklist score and pathology is well known for this type of
nevus, which is also called black nevus.
Checklist
Asymmetry
Atypical network
Total score 1
Figure 52 Nevus
In contrast to the lesion above, the checklist score for this nevus is just 1. There is no significant
asymmetry of structure with only delicate foci of blue-white structures in the centre of the lesion. No
atypical pigment network can be discerned.
28
1

Checklist
Asymmetry
Atypical network
Total score 2
Figure 53 Nevus
This lesion also has a checklist score of 2. This example shows the limitations of the 3-point checklist.
There is asymmetry because the lower half does not mirror the upper half. Also note that the pigment
network is atypical (arrows). Blue-white structures are not observed.
Checklist
Asymmetry
Atypical network
Total score 1
Figure 54 Nevus
This lesion is asymmetrical because the left side is not a mirror image of the right side. The line segments
of the pigment network are not thick, dark, or branched; therefore, it is not atypical. Do not confuse the
central hypopigmentation (asterisk) with blue-white structures.
29
Checklist
Asymmetry
Atypical network
Total score 2
*
*
*
Figure 55 Melanoma
There are two strikingly positive features present here—asymmetry and blue-white structures. Because
there are also a few satellite lesions (circle), it should be excised with high priority. Clear-cut asymmetry of
shape and structure and conspicuous blue-white structures (asterisks) are seen throughout the lesion. No
pigment network is seen, not even at the periphery.
Checklist
Asymmetry
Atypical network
Total score 2
Figure 56 Nevus
The atypical pigment network (circle) in this asymmetrical lesion is worrisome, and the lesion should be
excised. No blue-white structures are seen. Although the histology was benign, this dermoscopic picture
might also be seen in in situ melanoma.
30
1

Checklist
Asymmetry
Atypical network
Total score 2

The checklist score for this lesion is 2; because it is nodular, excision is recommended. Note the
asymmetry of color and structure and numerous blue-white structures throughout the lesion. No pigment
network can be identified.
Checklist
Asymmetry
Atypical network
Total score 2
Figure 58 Nevus
Two of the 3-point checklist criteria are present. Asymmetry of color and shape is evident, and centrally
located blue-white structures (circle) are seen. Because of a 3-point checklist score of 2, excision of this
lesion is recommended.
31
Checklist
Asymmetry
Atypical network
Total score 0
Figure 59 Nevus
The checklist score for this lesion is zero.
Checklist
Asymmetry
Atypical network
Total score 2

This nodular lesion scores 2, so it should be excised. There is asymmetry of color and structure. Note the
few blue-white structures (arrows) in the absence of a pigment network.
32
Pattern analysis
Dermoscopic criteria for specific diagnoses
2
Dermoscopic analysis of pigmented skin lesions is or gray. Modifications of the pigment network vary
based on four algorithms: with changes in the biologic behavior of melanocytic
skin lesions, and these variations therefore merit
• pattern analysis;
special attention.
• the ABCD rule;
• Menzies’ 11-point checklist; and
• the 7-point checklist Globular pattern
Variously sized, round to oval brown structures fill
The common denominator of all these diagnostic
these melanocytic lesions. This pattern can be found
algorithms is the identification and analysis of
in congenital and acquired melanocytic and Clark
dermoscopic criteria found in the lesions. The
(dysplastic) nevi.
majority of the dermatologists who participated in the
second consensus meeting were proponents of pattern
analysis. The basic principle is that pigmented skin Homogeneous pattern
lesions are characterized by global patterns and This pattern is characterized by a diffuse, uniform,
combinations of local criteria. structureless color filling most of the lesion. Colors
include black, brown, gray, blue, white, or red.
A predominantly bluish color is the morphologic
Four global dermoscopic patterns for hallmark of blue nevi.
melanocytic nevi
Reticular pattern Starburst pattern
The reticular pattern is the most common global The starburst pattern is characterized by the presence
pattern in melanocytic lesions. It is characterized by a of pigmented streaks and/or dots and globules in a
pigment network covering most parts of a lesion. The radial arrangement at the periphery of a melanocytic
pigment network appears as a grid of line segments lesion. This pattern is the stereotypical morphology in
(honeycomb-like) in different shades of black, brown, Spitz nevi.
33
Four global patterns
for melanocytic nevi
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 61 Nevus
The reticular type is probably the most common dermoscopic feature of a flat acquired melanocytic
nevus. It is characterized by a typical pigment network that fades out at the periphery. There are also a
few small islands of hypopigmentation—a common finding in benign nevi. The histopathologic distinction
between a junctional nevus and a compound nevus is commonly given, but the distinction cannot always
be made dermoscopically. Moreover, it is clinically irrelevant.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 62 Nevus
Here is another example of the morphology seen with the reticular type of banal nevus. The quality of the
typical pigment network demonstrates darker and thicker lines. The benign nature of this lesion is
emphasized by the fading out at the periphery of the pigment network.
34
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
*
* *
Figure 63 Nevus
This is a reticular-type lesion with a few dots. In the center of the lesion, the lines of the pigment network
are slightly thicker and more heavily pigmented (circle). In addition, there are a few dark-brown dots
(arrows) and a hint of a blue-white structure (asterisks). Again, note the fading out of the pigment network
along the entire periphery of the lesion representing an important clue that this is a benign melanocytic
lesion. This can also be called a Clark, dysplastic, or atypical nevus; it is not a melanoma.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 64 Nevus
This lesion is characterized by a typical pigment network and numerous dots, which are situated on the
crossing points of the network lines. In the background, diffuse blue-white structures can be seen
covering most of the lesion. Histopathologically, the diffuse blue-white structures represent a dense
infiltrate of melanophages in the papillary dermis. The differentiation between a junctional and a
compound nevus is not possible dermoscopically.
35
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 65 Nevus
A reticular-homogeneous pattern, as seen here, can be seen in banal nevi. In the center, there is homogeneous
black pigmentation (black lamella), and at the periphery there is an annular distribution of a typical pigment
network. Once again, the pigment network fades at the periphery—a sign of a benign nature. If this was a solitary
lesion, in situ melanoma would be the differential diagnosis. Most people with this dermoscopic appearance
have multiple similar-appearing nevi, favoring low-risk pathology. Tape stripping can peel away the black lamella
and allows one to see whether there are any underlying typical or atypical structures.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 66 Nevus
The unusual type of reticular-homogeneous pattern seen here is more often found in younger pediatric
patients. In the center of the lesion, there is homogeneous hypopigmentation (not to be confused with the
bony-milky white color of regression), and this is surrounded by a small rim of pigment network. The lines
of the pigment network are thickened and the meshes are slightly irregular. The overall architecture of the
network, however, is symmetrical and regular.
36
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 67 Nevus
A stereotypical reticular pattern is seen here. The pigment network is typical, but unevenly distributed and
fades out at the periphery. In addition, there are hypopigmented areas throughout the lesion (arrows). This
nevus does not reveal criteria used to diagnose melanoma (melanoma-specific criteria). Because of the
uneven distribution of the pigment network and variations in the shades of brown, the novice
dermoscopist should consider excision or close dermoscopic and clinical follow-up.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 68 Nevus
The patchy reticular pattern shown here is associated with an uneven distribution of a typical pigment
network. The intensity of pigmentation of the lines alternates, giving this pigment network a patchy
appearance, and is similar to Figure 67. The general principle to remember is that any unevenness of
relatively regular-appearing criteria is a minor cause for concern.
37
Reticular pattern
Globular pattern
Homogeneous pattern
* *
Starburst pattern
Figure 69 Nevus
This nevus shows a variation of reticular-pattern morphology. Note the zone of homogeneous
hypopigmentation (asterisks) in the center. This is not an area of regression that would be seen in
melanoma. It is not bony-milky white.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 70 Nevus
This dermoscopic picture is very worrying. The reticular pattern with eccentric hyperpigmentation
dermoscopically simulates in situ melanoma arising in a pre-existing nevus. The upper right half of this
lesion is characterized by a slightly atypical pigment network (arrows). On the left lower side, there is an
area of homogeneous hypopigmentation with a few foci of delicate pigmentation commonly seen in
benign nevi. Do not hesitate to excise a lesion that looks like this as soon as possible. The final
histopathologic diagnosis is in situ melanoma within a pre-existing nevus in 10% of similar-appearing
lesions. In this case, the diagnosis was Clark (dysplastic) nevus, compound type.
38
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 71 Nevus
This is a rather unusual combined nevus, with a dome-shaped globular nevus on the lower left site and
a variation on the theme of a flat reticular nevus on the upper right site. This lesion should undoubtedly be
excised because the differential diagnosis represents a hypomelanotic nodular melanoma arising within
a superficial melanoma or a pre-existing dysplastic (Clark) nevus. However, this lesion turned out to be a
dysplastic (Clark) nevus adjacent to a benign dermal nevus.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 72 Nevus
This predominantly reticular pattern with a few small globules centrally is commonly observed in benign
nevi. The unusual aspect of this lesion is the finger-like projection at 2 o’clock (arrows) characterized by a
broken-up pigment network intermingled with some globules. This lesion was excised and
histopathologically diagnosed as dysplastic (Clark) nevus, compound type.
39
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 73 Nevus
This light-brown pinkish lesion reveals a central hypopigmented homogeneous area surrounded by a
subtle, not very pronounced pigment network in a ring-like fashion. The unusual aspect of this lesion is its
pinkish color, and in the absence of any history of growth, annual follow-up is the management approach
we choose for this patient.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 74 Nevus
This lesion can be regarded as a typical example of a reticular melanocytic proliferation. There is a central
zone of hyperpigmentation. The pigment network has rather regular qualities throughout the lesion.
However, it does not thin out nicely along the periphery as commonly observed in reticular nevi. Because
of this dermoscopic finding and heavy pigmentation, this is potentially a high-risk lesion.
Histopathologically, this was diagnosed as a junctional type of dysplastic (Clark) nevus. Novice
dermoscopists should not hesitate to excise lesions that look like this.
40
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 75 Nevus
This is another example of a reticular-homogeneous nevus with an annular reticular pattern in the
periphery and large central homogeneous hypopigmented area. The color of the hypopigmented area is
not bony-white as observed in regressive melanoma, and because of the overall symmetry of this lesion,
annual follow-up can be advised confidently by the novice dermoscopist.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 76 Nevus
This lesion has a uniform reticular pattern with only a delicate focus of paracentral hyperpigmentation
(circle). The pigment network is typical and slightly fades out at the periphery. The overall shape of the
lesion, however, is a bit asymmetric and lesions like this one should always be followed up.
41
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
*
*
Figure 77 Nevus
This is another example of the variation of morphology with the reticular pattern. In contrast to Figure 76,
the pigment network here is mostly atypical with a tendency to stop abruptly at the periphery (arrows).
Central hyperpigmented areas (asterisks) are also seen. This dysplastic (Clark) nevus simulates in situ
melanoma and should be excised.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 78 Nevus
This is a predominantly reticular type of nevus with a pigment network fading out nicely at the periphery.
In our opinion, this is the most common type of benign nevus in men. Still, as a rule, we do recommend
annual follow-up and self-monitoring of reticular nevi.
42
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 79 Nevus
This shows a stereotypical globular pattern of a benign nevus. There are numerous dots and globules of
similar shape and varying size throughout the lesion. No melanoma-specific dermoscopic criteria are
seen. This pattern is most commonly seen in adolescents but can also be found in adults. The
histopathology could show a junctional or compound nevus.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 80 Nevus
This shows one of the many variations of the morphology seen with the globular pattern. The most
relevant aspect of this lesion is the even distribution of closely packed, similar-appearing dots and
globules. In addition, there are a few milia-like cysts in the center of the lesion (arrows). Milia-like cysts are
not seen only in seborrheic keratosis.
43
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 81 Nevus
This globular pattern shows dots and globules that are not closely packed together, are similar in size and
shape, and have a slightly uneven distribution. No melanoma-specific criteria are seen in this banal lesion.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 82 Nevus
Most of this lesion is characterized by homogeneous light-brown pigmentation and subtle dots and
globules (arrows).
44
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 83 Nevus
This image shows a more worrisome variation of the globular pattern. Numerous dots and globules are
unevenly distributed throughout the lesion (circle) and vary in size and shape.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 84 Nevus
Here is another globular type of nevus. Numerous light-brown to blue-gray dots and globules, which are
of similar size and shape, are distributed regularly throughout the lesion. The only worrisome area is a
collection of about 15-20 gray globules (circle), which prompted the excision of this compound type of
Clark (dysplastic) nevus. Study lesions carefully to look for subtle yet potentially high-risk criteria.
45
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 85 Nevus
This is another stereotypical example of the globular pattern of nevus, in which the globules are very easy
to see. In the center of this lesion, numerous dark-brown dots and globules with a rectangular shape
(cobblestone-like) are present and are surrounded by a rim of brown pigmentation. Dermoscopically, this
lesion gives the impression of a papillomatous or raised character. Histopathologic examination revealed
a compound nevus.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 86 Nevus
The globular pattern seen here is similar to that in Figure 85, yet the globules are not that easy to see. The
lesion is composed of closely packed gray dots and globules. No other dermoscopic criteria are
observed. The variation of the color might alarm the inexperienced dermoscopist. Remember, if in doubt,
cut it out. This was a benign nevus. After seeing and excising a few lesions with this dermoscopic
appearance, the dermoscopist will feel more comfortable about not excising lesions that look like this.
46
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 87 Nevus
This lesion shows again a globular pattern. It contains numerous brown to gray globules, which are evenly
distributed throughout the lesion. The gray globules are situated predominantly in the center of the lesion
and correspond to nests of pigmented nevus cells in the papillary dermis. Remarkably, globular nevi
represent the stereotypical nevus subtype among children and teenagers.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 88 Nevus
It is amazing to see the many different variations on the theme of globular nevi. In the previous pages,
we have seen quite a few benign globular nevi, but all are morphologically different and unique.
The striking aspect of this uniformly pigmented globular nevus is its dark brown pigmentation. We are
happy to follow this nevus and recommend self-monitoring.
47
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 89 Nevus
This globular nevus raises at least the orange flag because the globules composing this lesion vary in size,
shape, and color and are also slightly unevenly distributed throughout the lesion. Because there was also
a concern from the patient in regard with this lesion, a deep shave biopsy was performed. The final
histopathologic diagnosis was a compound type of dysplastic (Clark) nevus.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 90 Nevus
Numerous irregularly sized brownish dots and globules are seen throughout this lesion. Although it is
very small, the dermoscopic asymmetry is striking. The pinkish color is an important clue that this could
be a high-risk lesion. Because of its high-risk appearance, a lesion like this one warrants a second
histopathologic opinion if it is signed out as a benign nevus as was the case here.
48
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 91 Nevus
One has to look carefully to recognize that this heavily pigmented nevus reveals a globular and not a
homogeneous pattern in its central part. The lighter pigmented peripheral ring displays a pattern
reminiscent of globules and reticulated lines telling us that in morphology there is always an overlap of
features. We were confident that this lesion was a variation on the theme of a benign globular nevus and
recommended annual follow-up and self-monitoring.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 92 Nevus
In some instances, the distinction between a globular and a reticular nevus is not that easy, as evidenced
by this irregularly outlined lesion. In the central parts, a pigment network characterized by thickened lines
and small holes prevail, whereas toward the periphery, a more globular pattern becomes evident.
Although we are raising the orange flag here, we felt confident that this lesion requires only follow-up.
49
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 93 Nevus
This lesion is characterized by diffuse homogeneous pigmentation. There is a subtle rim of
radially oriented line segments at the periphery, which represent streaks (arrows), and blue-white
structures in the center (circle). The dermoscopic differential diagnosis includes Clark (dysplastic) nevus
and Spitz nevus.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 94 Nevus
Apart from the blue-white structures and tiny dots in the central part (circle), this lesion displays a rather
uniform subtle reticular pattern, which made us comfortable to follow up this lesion. We are well aware
that some colleagues would prefer to excise a lesion like this one for peace of mind. Also the clinical
image was reassuring for us that we were dealing with a nevus.
50
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 95 Nevus
This lesion is characterized by a reticular-homogeneous pattern. Please note the focus of atypical
pigment network (circle). In addition, the left lower part of the lesion exhibits blue-white structures, and
these two signs are sufficient to warrant excision. In the realm of dysplastic (Clark) nevus, it is difficult to
determine whether a lesion is low or high risk dermoscopically; therefore, the novice is best advised to
excise gray-zone lesions as this one.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 96 Nevus
This is another example of a benign globular nevus with globules slightly varying in size, shape, and
coloration. Despite the irregular outline of this lesion, no action but follow-up has to be undertaken.
51
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 97 Nevus
This is a rather commonly observed variation of the theme of a reticular type of nevus. These lesions are
frequently found in adults. We judge this pigment network as typical and rather uniformly distributed. It is
fading out particularly in the lower right part of the lesion. Without any specific history, we were happy
with follow-up of this nevus and, in addition, recommended self-monitoring.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 98 Nevus
This lesion is a variation of the homogeneous-reticular type of nevus reminiscent of a so-called black
nevus. Multiple jet-black homogeneous zones are seen at the periphery. Use tape stripping for this black
lesion mimicking in situ melanoma.
52
2
Pattern analysis
Reticular pattern
* Globular pattern
Homogeneous pattern
* * Starburst pattern
Figure 99 Nevus
This is a dome-shaped melanocytic nevus that reveals a subtle globular pattern with numerous light-
brown dots and globules throughout. Multiple blood vessels with dotted (asterisks) and comma-like
appearances (arrows) are seen. There are also a few milia-like cysts (circles), but this is not a seborrheic
keratosis. Clinically this lesion could be confused with a basal cell carcinoma, but the vessels in a basal
cell carcinoma are thick and branched (arborizing) and there would be no yellow color.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 100 Nevus

This lesion has a globular pattern containing numerous brownish-blue dots and globules, which vary in
size and shape, and a central irregular brownish blotch (circle).
53
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 101 Nevus

This clinically broad sessile nodule has a papillomatous surface and a few irregularly shaped comedo-like
openings (arrows). Sometimes it is not possible to differentiate the comedo-like openings from
globules. The thin pigmented lines are not pigment network but pigmentation in the furrows of the lesion.
The soft, compressible nature points to it being low risk. Palpate suspicious lesions, but if in doubt,
cut them out.

Reticular pattern
Globular pattern
Homogeneous pattern
* Starburst pattern
Figure 102 Nevus

This is another broad, sessile nodule characterized by a papillomatous surface. There are some comedo-
like openings (arrows) and a few bluish dots and globules (asterisks). These can be confused with blue-
white structures.
54
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 103 Nevus

Here is another papillomatous dermal nevus. There are subtle blue-white structures (asterisk) in the lower
half of this dome-shaped nodule. This is another lesion to palpate. Compressibility and easy movement
from side to side are good clinical signs in favor of a benign nature.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
*
*
Figure 104 Nevus

It is common to see a papillomatous nevus (circle) in transition with a flat melanocytic nevus (solid arrow).
The flat component can give a worrisome clinical appearance, which in most cases is not high risk when
viewed with dermoscopy. The dome-shaped nodule is characterized by numerous comedo-like openings
(asterisks). In addition, there are comma-like vessels (open arrows) throughout the lesion. Comma-shaped
vessels are not characteristically seen in melanomas. At the lower margin, there is a flat brownish area
with regular dots and globules.
55
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 105 Nevus

This papillomatous dermal nevus is relatively featureless, but the blood vessels (arrows) might make one
consider basal cell carcinoma in the differential diagnosis. The vessels of basal cell carcinoma, however,
are linear, sharp in focus, and branched (arborizing). This elevated papillomatous nodule reveals a
homogeneous pattern and has a light-brown color. Commonly these nevi are irritated due to incidental
traumas.

Reticular pattern
Globular pattern
* Homogeneous pattern
*
Starburst pattern
Figure 106 Nevus

In this bizarre dermoscopic picture, there are several densely aggregated exophytic papillary structures
and ridges, which look like globules. There are also a few irregular crypts and furrows (arrows), which
represent a variation of the morphology seen with comedo-like openings. In the center, there is an
accumulation of yellowish-white keratotic material (asterisks). Palpate this lesion and it will be soft, which
will be one criterion in favor of it being a banal nevus.
56
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
* Starburst pattern
*
*
Figure 107 Nevus

This lesion is similar to that in Figure 106 and is composed of densely aggregated exophytic papillary
structures intermingled with furrows (asterisks). In addition, there are a few regular brown dots and
globules (arrow) and blue-white structures. A small banal reticular-type nevus is seen in the right lower
corner.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 108 Nevus

This elevated nevus on the forehead is characterized by some light- to dark-brown dots and globules,
particularly in the center of the lesion (circle). Please note the presence of roundish holes representing hair
follicles. Closer scrutiny shows hairs in the center of a few follicles. These nevi are so often inflamed due
to ingrown hairs and ruptured hair follicles. Because of the relatively pronounced pigmentation, we raised
the orange flag. This benign nevus was excised as requested by the patient.
57
Reticular pattern
* Globular pattern
Homogeneous pattern
Starburst pattern
Figure 109 Nevus

Here is a very subtle type of globular pattern in a flat melanocytic nevus with numerous tiny dots and
multifocal hypopigmentation (asterisks). This pattern can be seen with congenital or Clark (dysplastic)
nevi.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 110 Nevus

This image shows one of the stereotypical patterns seen with congenital nevi. It is a reticular pattern with
islands of light, featureless color similar to those seen in Figure 109, but more dramatic. The pigment
network in the central portion is more heavily pigmented and the lines are thickened when compared to
those at the periphery. There is also a focus of blue-white structures (arrow). Commonly, congenital nevi
look worrisome with dermoscopy but not histologically. Islands of normal skin þ islands of criteria ¼
congenital melanocytic nevus.
58
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 111 Nevus

The globular pattern seen here is intermingled with roundish white holes and is characterized by
numerous tiny bluish dots and globules (circle) situated predominantly in the center of the lesion, and
many light-brownish globules peripherally. The overall dermoscopic architecture of this lesion is
symmetrical and regular, and excision is not indicated.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 112 Nevus

This lesion shows another of the many variations of the globular pattern with numerous hypopigmented
roundish areas. This pattern is very suggestive of a congenital melanocytic nevus. Numerous brownish
dots and globules are evenly distributed throughout the lesion. In the upper section, there is an oval dark-
brown pigmented area. This blotch (circle) could represent high-risk pathology, and for this reason, the
59
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 113 Nevus

This lesion with a particular homogeneous pattern is a congenital speckled nevus, also called nevus
spilus. There is a rather characteristic pattern of several brownish homogeneous dots and clods on a
homogeneous light-brown to skin-colored background. The novice may be confounded by this lesion and
consider an unusual melanoma in the differential diagnosis. We felt confident to recommend follow-up
and self-monitoring of this special type of congenital nevus.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
*
* *
Figure 114 Nevus

This papillomatous nevus is composed of a few exophytic papillary structures (circles) and some
comedo-like openings (asterisks). In addition, there are a few milia-like cysts (arrows) and blue-white
structures. If a worrisome-looking lesion like this is palpated, it should be soft and compressible—this
sign indicates that it is benign.
60
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 115 Nevus

This reticular nevus is characterized by a pigment network pattern that immediately raises our suspicion.
There are certainly areas with a thickened and branched pigment network (circles) and also the other
parts of the pigment network reveal some features of irregularity. This dysplastic (Clark) nevus simulates
in situ melanoma and should be excised.

Reticular pattern
Globular pattern
Homogeneous pattern
* Starburst pattern
*
* *
Figure 116 Nevus

This nevus is characterized by the presence of numerous hairs, which is diagnostic of a congenital
melanocytic nevus. There are also brownish globules throughout the lesion intermingled with numerous
small blue dots (asterisks), which represent collections of melanophages in the papillary dermis and raise
the suspicion of a regressing melanoma. Against the dermoscopic diagnosis of melanoma are the
presence of multiple hairs and symmetry of color and structure.
61
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 117 Nevus

Here is another example of a nevus with dark hairs, which might be best interpreted as a small congenital
melanocytic nevus on the face. The dermoscopic hallmark of this lesion is a regular pseudopigment
network formed by numerous round areas, which represent follicular openings. This criterion is site
specific. Because of the dermoscopic symmetry of color and structure, a melanoma can be ruled out with
certainty. Pigment network is not the same as pseudopigment network.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 118 Nevus

This is a stereotypical example of a nevus spilus, which is characterized by several foci (circles) of a subtle
brownish pigment network on a diffuse light-brown background. Each of these spots is reminiscent of a
reticular type of nevus. Melanoma can develop in a nevus spilus; therefore, dermoscopy is a useful tool
for examining these lesions. Look for the same high-risk criteria as for other types of melanocytic nevi.
62
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 119 Nevus

This congenital nevus exhibits a reticular-homogeneous pattern with the latter in the center of the lesion.
The periphery is characterized by a regular patchy distribution of small foci of typical pigment network
arranged in an annular pattern. Because of the overall rather symmetrical aspect of this lesion, we are
raising the green flag.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 120 Nevus

At higher magnification, this congenital nevus has a very worrisome appearance dermoscopically
because there is asymmetry of color and also of structure. However, in melanocytic lesions larger than
1 cm in diameter, we have always taken into consideration the clinical appearance. It is well known that
dermoscopy of congenital nevi may be confounding and lead us astray. Putting together the clinical and
the dermoscopic features of this lesion, we are confident to follow up this congenital nevus.
63
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 121 Nevus

This is a stereotypical example of a blue nevus characterized by diffuse homogeneous pigmentation.
There is also a small rim of brownish pigmentation. The differential diagnosis of this blue nevus is a
hemangioma and nodular or cutaneous metastatic melanoma. The history of the lesion is vital to make the
correct dermoscopic diagnosis.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 122 Nevus

This figure shows a stereotypical example of a blue nevus. Note the homogeneous blue pigmentation
throughout the lesion, a morphologic finding that is observed basically only in blue nevi and in tattoos.
Very rarely you can find a similar dermoscopic appearance in rapid-growing cutaneous melanoma
metastases. In the latter instance, patient history data will lead you to the diagnosis of melanoma
metastasis.
64
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 123 Nevus

This image shows another example of a typical blue nevus. The whitish area in the center of the lesion
(circle) is just a scale. If there is no history of growth, we can confidently raise the green flag here.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 124 Nevus

This is a blue nevus with fibrosis (circle) simulating a regressive Clark (dysplastic) nevus or even a
regressing melanoma. There is homogeneous blue pigmentation surrounding a whitish area,
which corresponds histopathologically to a prominent zone of fibrosis in an otherwise typical blue nevus.
65
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
*
Figure 125 Nevus

This blue nevus is a predominantly firm nodule with a smooth surface. The clinical differential diagnosis
includes hypomelanotic melanoma, dermatofibroma, or dermal nevus. The nevus has a diffuse light-
brownish color bordered by small zones of darker pigmentation and blue-white structures (asterisks). No
other dermoscopic criteria are seen. Because a hypomelanotic melanoma cannot be ruled out with
certainty, a lesion with this dermoscopic picture should be excised.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 126 Nevus

This variation of the morphology seen in blue nevi simulates hypomelanotic melanoma and is
characterized by a fusion of diffuse bluish and whitish zones. There is a complete lack of individual
dermoscopic criteria.
66
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 127 Nevus

This is an example of a blue nevus with diffuse bluish-brown pigmentation. A lesion like this one raises
important differential diagnostic considerations, such as Spitz nevus and nodular melanoma. Although
there is only a small probability that this is indeed a nodular melanoma, we are raising the red flag here.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 128 Nevus

This lesion is a variation of a blue nevus. Dermoscopically, it is characterized by homogeneous blue and
gray color surrounded by a faint ring of lighter blue color. There are no hints of local dermoscopic
features, particularly melanoma-specific criteria. Nevertheless, because of the lesion’s asymmetry of
contour and color, excision is justified to rule out a melanoma. The history is also an important factor in
this case.
67
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 129 Nevus

This is a stereotypical example of a Spitz nevus with a starburst pattern. There is a symmetrical ring of
streaks around the entire lesion and a central blue-white structure. Both these dermoscopic features are
commonly found in Spitz nevi. If the streaks are not at all areas of the periphery, it could be the
dermoscopic picture of a melanoma. A starburst pattern should immediately make one think of Spitz
nevus.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 130 Nevus

This lesion is also Spitzoid and similar to that in Figure 129, but the streaks at the periphery are not so
dramatic. It also has the starburst pattern. As a rule, excision of a lesion with this dermoscopic
appearance is recommended, particularly if the individual is over 14 years of age. The patient can be
reassured that in most cases the lesion will not be a melanoma.
68
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 131 Nevus

This is predominantly a globular type of Spitz nevus, which dermoscopically raises a suspicion of
melanoma. It is a relatively symmetrical lesion characterized by numerous brown to bluish globules rather
evenly distributed throughout the lesion. In the left lower corner of the lesion, there are several dotted
vessels (circle). The decision about whether to closely follow or excise a lesion that looks like this depends
on the clinical setting.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 132 Nevus

This lesion is similar to the one above, but the dots and globules are more prominent. This globular pattern
can be seen in banal, dysplastic (Clark), and Spitz nevi as well as rarely in melanomas. In addition, there are
hints of streaks in the periphery (6-7 o’clock) and a so-called negative pigment network in the central parts
of the lesion, both features suggestive of a Spitz nevus. However, because of the equivocal dermoscopic
appearance, this lesion was excised and diagnosed histopathologically as a Spitz nevus.
69
DERMOSCOPY - The Essentials Four global patterns
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 133 Nevus

This is a small pigmented Spitz nevus (commonly referred to as pigmented spindle cell nevus or Reed
nevus) with a rather typical starburst pattern. In addition, there is a thickened and branched superficial black
pigment network throughout the lesion with an accentuation at the periphery. The differential diagnosis
includes an in situ melanoma, and therefore the lesion should be excised. Small lesions can be high risk.

Reticular pattern
Globular pattern
* Homogeneous pattern
* Starburst pattern
Figure 134 Nevus

This lesion shows another variation of the morphology seen in Spitz nevi. There is dermoscopic symmetry,
a blue-white structure in the center, and streaks with a subtle starburst pattern (asterisks) at the periphery.
Because a melanoma cannot be ruled out with certainty, this lesion should be excised.
70
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 135 Nevus

The starburst pattern of a Reed (pigmented Spitz) nevus should by now be recognizable. Please note the
many streaks at the periphery of this lesion. The numerous tiny white punctate areas are not the milia-like
cysts of a seborrheic keratosis but eccrine duct openings. The differential diagnosis of this lesion would
be a Clark (dysplastic) nevus or a melanoma; therefore it should be excised.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 136 Nevus

This lesion shows another variation on the morphology observed in Spitz (Reed) nevi and is characterized
by numerous globules distributed evenly varying in color from light brown, dark brown, blue to black.
The life cycle of a Spitz (Reed) nevus starts with a globular pattern, followed by the starburst pattern and
finally the homogeneous pattern before the lesion starts to involute. Based on the clinical constellation,
however, we are raising here the red flag.
71
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 137 Nevus

It is impossible to see too many variations of Spitz (Reed) nevi, so here is another classic one! The most
remarkable aspect of this lesion is a superficial black pigment network forming streaks that create a
starburst pattern that is a highly specific sign for Spitz (Reed) nevi. Still, your management decision should
always be based on the clinical constellation and never on the dermoscopic findings alone. If this lesion,
for example, occurs on the lower leg of a middle-aged woman, raise the red flag.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 138 Nevus

This jet-black Spitz (Reed) nevus is not as easy to diagnose as that in Figure 137. Although a rather typical
starburst pattern can be observed, there is a striking asymmetry at least in one axis and therefore a
melanoma should be ruled out, particularly in adults.
72
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 139 Nevus

Spitz nevi have many faces! This one is harder to diagnose because the dermoscopic features are not
distinctive. It has a central diffuse blue-white structure and also a few black dots and globules (circle).
Please note streaks (arrows) arranged radially along the periphery of the lesion suggestive of a starburst
pattern. The dermoscopic differential diagnosis includes a dysplastic (Clark) nevus, a Spitz nevus, and an
in situ melanoma, so it should be excised.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 140 Nevus

This almost structureless lesion has multiple colors—a diffuse black to blue-white coloration in the center
and shades of brown in the periphery. There is no clear-cut pigment network visible, but one can
recognize a hint of a starburst pattern. If a lesion cannot be categorized with certainty, then it should be
excised to rule out melanoma. The large blue-white structure and the starburst pattern favor a pigmented
Spitz (Reed) nevus.
73
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 141 Nevus

This pigmented Spitz nevus (or Reed nevus) clinically strongly mimics a melanoma. However,
dermoscopically a classic starburst pattern can be recognized easily and therefore the diagnosis of a
pigmented spindle cell (Reed) nevus (also called pigmented Spitz nevus) can be made with confidence.
Particularly in children under age 12, this lesion can be followed up and every so often will involute within
a few years. In elder children and in younger adults, a lesion like this one always should be removed. Most
probably you will not see a similar lesion in adults older than 40 years.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 142 Nevus

This lesion can be categorized as a globular type of Spitz nevus. Because of the asymmetry and multiple
colors, it is another lesion that simulates a melanoma. Remember that dermoscopy is not 100%
diagnostic of any single lesion. There are numerous asymmetrically located dots and globules (arrows),
irregular brown streaks (circle), and blue-white structures.
74
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 143 Nevus

This pigmented Spitz nevus is characterized by a globular pattern and again mimics melanoma. There is a
central blue-white structure and several irregular black dots and globules, more or less unevenly
distributed throughout the lesion, creating structural asymmetry. No pigment network can be identified.
Because this lesion was present in a young adult, an excisional biopsy was performed immediately.
Fortunately, the final histopathologic diagnosis was a Spitz nevus.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 144 Nevus

On initial impression, this lesion should appear high risk because it is so dark. Remember that black color
is not always an ominous sign. This is another variation of a homogeneous and globular Spitz nevus.
Dermoscopically, it is a symmetrical lesion characterized by a large homogeneous central zone of dark
pigmentation surrounded by a thin rim of brown dots and globules. A subtle blue-white structure can also
be seen throughout the centre of the lesion. Melanoma cannot be ruled out with certainty; therefore, this
75
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 145 Nevus

A very experienced dermoscopist might recognize this as a pigmented Spitz nevus (Reed nevus). There is
a superficial black pigment network and a quite typical starburst pattern with numerous streaks (arrows)
aligned along the circumference of the lesion. Still, we do recommend excision of this clinically and also
dermoscopically rather worrisome lesion. Don’t be a “hero” and excise any pigmented lesion when you
are not absolutely confident. Keep in mind that about 20% of Spitz nevi can mimic melanoma clinically
and dermoscopically.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 146 Nevus

This dome-shaped lesion reveals dermoscopically several brown to black dots and globules distributed
unevenly throughout the lesion. The differential diagnosis of this Spitz nevus is an early nodular melanoma
and therefore excision of this lesion is a must! Be happy when your pathologist finally diagnoses here a
Spitz nevus.
76
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 147 Nevus

This pink homogeneous-globular lesion looks not particularly worrisome but is a Spitz nevus simulating
amelanotic melanoma. The most remarkable aspect of this lesion is a central negative pigment network,
also called reticular depigmentation. There is a pinkish, rather homogeneous pigmentation throughout.
There are also numerous light-brown to pinkish dots throughout the lesion, but one has to look hard to
find them. Relatively featureless pinkish lesions should be excised because occasionally they are
melanomas. Pink color beware!

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Figure 148 Nevus

Hard to believe that this is not a melanoma—this is a combined nevus composed of a pigmented spindle
cell (Reed) nevus (pigmented Spitz nevus) with a rather stereotypical starburst pattern on the right side
and an unusual globular-reticular type of dysplastic (Clark) nevus on the left side. There is no doubt a
lesion that displays this degree of asymmetry in color, shape, and structure needs to be excised. And
even when your pathologist diagnoses this lesion as a benign nevus, we would recommend discussion of
this lesion with him or her to make sure that a melanoma has not been missed. 77
Diagnosis of melanoma using five unevenly distributed in a lesion. A symmetrical
melanoma-specific criteria arrangement of streaks around an entire lesion is most
often found in Spitz nevi, but this pattern can also be
Melanoma is most often characterized by a
seen in melanomas.
multicomponent global appearance. The
multicomponent pattern is defined as the presence of Irregular dots and globules
three or more distinct dermoscopic areas within a
given lesion. For example, it might be made up of Dots and globules are sharply circumscribed, round to
separate zones of pigment network, clusters of dots oval, variously sized, black, brown, or gray structures
and globules, and areas of diffuse hyper- or that can be subdivided as regular or irregular based on
hypopigmentation. Many combinations of criteria can their size, shape, and distribution in a lesion. Irregular
be seen with this high-risk global pattern. It is highly dots and globules have different sizes and shapes and
suggestive of melanoma but can also be found in basal are unevenly distributed throughout a lesion.
cell carcinoma. Rarely, it is seen in acquired and Histopathologically dots and globules may represent
congenital nevi and in non-melanocytic lesions, such aggregations of pigmented melanocytes, melanophages,
as seborrheic keratoses or angiokeratomas. or even clumps of melanin. Dots and globules can be
To diagnose melanoma, look for the melanoma- found in benign and malignant melanocytic lesions
specific criteria in a lesion. Melanoma-specific criteria and are usually irregular in melanomas.
can be seen in benign and malignant lesions but are
Irregular blotches
more specific for melanomas. Finding one or two is
enough to warrant a histopathologic diagnosis. Blotches refer to various shades of diffuse
hyperpigmentation that obscure the recognition of other
dermoscopic features such as pigment network, dots,
Atypical pigment network
and globules. Irregular blotches vary in size and shape
A low-risk pigment network can appear as a delicate with irregular borders. A well-demarcated blotch at the
thin grid or a honeycomb-like pattern of brownish periphery is very suggestive of melanoma.
lines over a diffuse light-brown background. Histopathologically blotches represent histopathologic
Histopathologically, the lines of the pigment network structures that share pronounced melanin pigmentation
represent elongated and hyperpigmented rete ridges, throughout the epidermis and upper dermis. Localized
whereas the lighter areas between the lines are dermal or diffuse regular blotches are suggestive of benign
papillae. This criterion represents the dermoscopic lesions, whereas localized or diffuse irregular blotches
hallmark of melanocytic lesions. Alterations are favor malignancy.
helpful to differentiate between benign and malignant
melanocytic proliferations. Blue-white structures
An atypical pigment network is characterized by black, Blue-white structures can appear as white scar-like
brown, or gray, thickened and branched line segments, depigmented areas (bony-milky white color) or bluish
distributed irregularly throughout the lesion. A sharp structureless areas, or combinations of both colors. Do
cutoff of an atypical pigment network at the periphery of not confuse white scar-like areas with
a lesion is even more suggestive of melanoma. hypopigmentation commonly seen in benign lesions.
Blue-white structures represent an acanthotic
Irregular streaks epidermis with compact orthokeratosis and
Streaks are dark linear structures of variable thickness pronounced hypergranulosis overlying a large
found at the periphery of a lesion. The term “streaks” melanin-containing area such as confluent nests of
includes radial streaming and pseudopods, which are heavily pigmented melanocytes or melanophages in
variations of the same criterion. Streaks represent the upper dermis with variable amounts of fibrosis.
discrete, linear, heavily pigmented, junctional nests of Whatever color variations are seen, blue-white
atypical melanocytes. Although streaks can be found structures are a high-risk criterion most often found in
in benign and malignant melanocytic lesions, they are melanomas. Blue-white structures can also be seen in
more specific for melanoma, especially when they are Spitz and Clark (dysplastic) nevi.
78
2
Pattern analysis
Five melanoma-
specific local criteria
Atypical network
Irregular streaks
Irregular dots/globules
Irregular blotches
1
* 2
Figure 149 Melanoma

This melanoma demonstrates significant asymmetry of color and structure, multiple vivid colors, and a
multicomponent global pattern (1, 2, 3). The melanoma-specific criteria are more than sufficient to make
the dermoscopic diagnosis, with asymmetrically located irregular streaks (black arrows), irregular dots
and globules (white arrows), and blue structures (asterisk).
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 150 Melanoma

Remarkably, this dermoscopically straightforward melanoma shows only subtle asymmetry of color and
structure. The melanoma-specific criteria found in this lesion include an atypical pigment network in a
ring-like distribution along the circumference of the whole lesion and a large central area covered by blue-
white structures.
79
Five melanoma-
Atypical network
* Irregular streaks
Irregular blotches
Figure 151 Melanoma

This dark black, rather sharply circumscribed lesion displays asymmetry in color, shape, and structure.
In addition to a large blue-white structure, there are at least three relevant melanoma-specific criteria
present, albeit not very prominent. Remnants of an atypical pigment network are visible at 11 o’clock
(circle), few atypical dots/globules are present adjacent to it (above asterisk), and variations on the theme
of irregular streaks are noted along the periphery of the lesion (arrows). Such a constellation of
dermoscopic findings allows diagnosing a melanoma with a very high level of confidence.
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 152 Melanoma

This lesion could be diagnosed as an unusual or atypical solar lentigo because of the moth-like
appearance of the border. However, it is very worrisome because there is significant asymmetry of color
and structure and the presence of blue-white structures (circle), a few irregular streaks (arrows), and also
irregular dots/globules throughout the lesion. In addition, there are areas with hints of an atypical pigment
network. The constellation of findings is virtually diagnostic of a melanoma on moderately sun-damaged
80 skin.
2
Pattern analysis
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 153 Melanoma

The white dots (white arrow) are not milia-like cysts but reflection artifacts from the photography of this
lesion under oil immersion. This lesion has only two melanoma-specific criteria. One is obvious—the
irregular blotch (circle), and one is hard to find—irregular streaks within the blotch (black arrows). Always
focus attention and look for subtle melanoma-specific criteria in a seemingly benign lesion. The very dark
and asymmetrically located irregular blotch is worrisome enough by itself to warrant an excision.
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 154 Melanoma

This melanoma has all of the melanoma-specific criteria from our algorithm and should be easy to
diagnose. There are areas with an atypical pigment network (black circle), irregular streaks asymmetrically
located in the lesion (open arrows), irregular dots and globules (solid arrows), irregular blotches (white
circles), and blue-white structures (asterisks). Clinically this lesion was in the gray zone of suspicion, but
this dermoscopic picture leaves no doubt that this is a melanoma.
81
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 155 Melanoma

The obviously present blue-white structures (asterisks) and irregular dots and globules (white arrows)
mean that this is a melanoma. If the irregular streaks (black arrows) and irregular blotches (white circles)
are missed, the significant asymmetry of color and structure plus the presence of two prominent
melanoma-specific criteria should be sufficient clues for the novice dermoscopist to remove a lesion that
looks like this.
Five melanoma-
1 Atypical network
Irregular streaks
Irregular blotches
2
3
Figure 156 Melanoma

This melanoma is harder to diagnose than that in Figure 155. The pinkish color (solid arrow), big
blue-white structure (circle), and multicomponent global pattern (1, 2, 3) are worrisome criteria. This lesion
also has irregular dots and globules (open arrows). This combination of criteria is more than enough to
warrant excision.
82
2
Pattern analysis
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 157 Melanoma

This strikingly asymmetric lesion is worrisome already at the first glance, although rarely the
histopathology of a lesion like this one will reveal only a dysplastic (Clark) nevus with severe atypia. Our
pathologist diagnosed here a melanoma. The melanoma-specific criteria underlining the diagnosis are a
blue-white structure (circle) in the lower half of the lesion and few foci of an atypical network (arrows).
Please note that the atypical network could easily be interpreted also as irregular streaks with a tendency
to form a network. Some colleagues think that the many morphologic faces observed with dermoscopy
could even be used for a Rorschach test!
Five melanoma-
Atypical network
Irregular streaks
3 Irregular blotches
* 4 Blue-white structures
1
2
Figure 158 Melanoma

This is a melanoma arising in a nevus. The remnants of the globular pattern of the nevus are still
evident (black circle). By definition, the dark area would not be considered to be an irregular blotch (white
circle) because it contains irregular dots and globules (asterisk) and a blue-white structure (arrow). It
should be featureless. Two of five melanoma-specific criteria are present plus a multicomponent global
pattern (1, 2, 3, 4) and multiple vivid colors. However, no matter how worrisome a dermoscopic picture
may look, some of the worst-looking lesions turn out to be benign.
83
DERMOSCOPY - The Essentials Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 159 Melanoma

This lesion is difficult to diagnose because one can easily interpret it clinically and dermoscopically as
irritated seborrheic keratosis. Keep in mind that also a melanoma can be irritated! There is only slight
asymmetry in shape and not even a hint of a pigment network. However, there is a large irregular blotch
(circle) and there are few irregular dots/globules (arrows) all probably representing old hemorrhagic crusts
of this ulcerated thin nodular melanoma. Please note the blue-whitish structure representing the
background of this lesion and note also the thin reddish rim particularly well visible in the left half of the
lesion.
Five melanoma-
Atypical network
Irregular streaks
* Irregular dots/globules
* Irregular blotches
Figure 160 Melanoma

This is another example of a superficial melanoma which sometimes even histopathologically is very
difficult to differentiate from a dysplastic (Clark) nevus with severe atypia. The asymmetry in color and
structure due to the presence of irregular streaks (asterisks) and irregular dots/globules (arrows) leads
even the novice to the diagnosis of a melanoma. In addition, there are blue-white structures clearly visible
in the central parts of this lesion.
84
2
Pattern analysis
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 161 Melanoma

It would be very unusual (although not impossible) to see such a vivid blue-white structure and asymmetry
of criteria in a benign lesion. There is an atypical pigment network (black circles). Do not confuse the
irregular dots and globules (arrows) with the follicular openings of a seborrheic keratosis. There are also
several areas with irregular blotches (white circles). This melanoma has four melanoma-specific criteria;
some are easy to see and others could be missed. It is not necessary to identify all five criteria to make
this dermoscopic diagnosis.
Five melanoma-
Atypical network
Irregular streaks
1 * * Irregular dots/globules
Irregular blotches
2
3
Figure 162 Melanoma

This is a small lesion but the blue-white structures and irregular blotches (white circles) make this
worrisome. One could argue whether the pigment network is typical or atypical. There are different areas
with irregular dots and globules. Some are black and some are bluish and “pepper-like,” representing
melanophages (asterisks). The multicomponent global pattern (1, 2, 3), blue-white structures, and irregular
blotches provide more than enough criteria to make the tentative dermoscopic diagnosis of melanoma.
85
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 163 Melanoma

In some instances, the diagnosis of superficial melanomas is very straightforward and should never be
missed particularly when dermoscopy is applied. Obviously in the left upper part of this melanoma,
regressive changes are observed; otherwise this lesion reveals all stereotypical dermoscopic criteria of a
full-blown melanoma. Not uncommonly there is an overlap between irregular streaks and irregular
blotches (circles). Note that each of the dermoscopic criteria has a wide variation of its morphologic
aspects and details. Never forget that melanomas do not read textbooks!
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 164 Melanoma

Clinically this is a relatively symmetrical lesion, but there is asymmetry of color and structure when viewed
with dermoscopy and there is a multicomponent global pattern. The blue-white structure (asterisk) is the
most obvious clue that this could be a melanoma. The pigment network is atypical (circles), with a hard-
to-see focus of streaks (open arrows). There are also irregular dots and globules (solid arrow). Once again,
some criteria are easier to see than others.
86
2
Pattern analysis
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 165 Melanoma

This melanoma shares many features with a dysplastic (Clark) nevus, clinically and dermoscopically, and
to pick it out in a patient with numerous large dysplastic (Clark) nevi can even be impossible. Sequential
dermoscopic monitoring is helpful in these patients. This lesion is characterized by a patchy reticular
pattern and numerous brown globules along its periphery. The standout morphologic features here are
the central blue-white structures and the brownish irregular blotches (arrows).
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 166 Melanoma

This superficial melanoma can be recognized easily even by a beginner because of the striking
asymmetry in shape, structure, and color. Closer scrutiny reveals some irregularly outlined black blotches
(circles), a few irregular streaks (arrows), and numerous irregular brownish to black dots/globules. Always
keep in mind that there are many variations of morphology of the classic dermoscopic criteria as
evidenced in this image.
87
Five melanoma-
Atypical network
Irregular streaks
*
Irregular blotches
*
Figure 167 Melanoma

This melanoma is rather difficult to diagnose and can be confused with a dysplastic (Clark) nevus despite
the fact that there is considerable asymmetry in structure and color. Most probably, the asymmetrically
located atypical pigmented network (circle) will catch your eye immediately, as will the blue-white
structures (asterisks) in the right half of the lesion. Completing the list of melanoma-specific criteria, there
are irregular dots/globules (arrows).
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 168 Melanoma

This heavily pigmented lesion is easily recognized as a melanoma or a pigmented basal cell carcinoma.
A distinction between these two malignant lesions often cannot be ascertained based on dermoscopic criteria
alone as evidenced by this observation. Of course, you always err on the side of caution and excise this lesion with
utmost priority. Melanoma-specific criteria clearly visible here are blue-white structures and black irregular dots/
globules. The many shiny white streaks (arrows) strikingly present throughout the lesion indicate that this image has
been captured with polarized light. However, the criterion of shiny white streaks (also called chrysalis structures)
does not help at all to differentiate between a melanoma and a pigmented basal cell carcinoma.
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2
Pattern analysis
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 169 Melanoma

This melanoma is characterized by at least three completely different morphologic areas. A dome-shaped
skin-colored nodule reminiscent of a dermal nevus, a pigmented area composed of brownish irregular
streaks (circle), and at 6 o’clock another pigmented patch comprising irregular dots/globules. No doubt
that we are dealing with a melanoma. Histopathology revealed that the skin-colored nodule was not a pre-
existing dermal nevus, but an amelanotic melanoma with a Breslow index of 2.2 mm. Always be very
cautious with nodular lesions within the context of a melanoma.
Five melanoma-
*
Atypical network
* Irregular streaks
* Irregular blotches
Figure 170 Melanoma

This is a very worrisome dermoscopic picture. Some criteria are very easy to see, while others are
camouflaged by intense pigmentation and are harder to find. Areas of atypical pigment network (circle)
and irregular dots and globules (asterisks) are difficult to see but will be found if one searches hard
enough. There is no comparison between the irregular streaks (black arrows) and irregular blotches (white
arrows) seen here and those in Figure 169. There are also well-developed blue-white structures.
89
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 171 Melanoma

Spitzoid, starburst, asymmetry of color and structure—this is therefore melanoma. There are streaks
(arrows) and areas without streaks. By definition, they are irregular streaks because they are not identified
in all areas at the periphery of the lesion. There are also irregular dots and globules and irregular blotches
throughout the lesion on a background of blue-white structures.
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 172 Melanoma

This is a verrucous melanoma arising within a pre-existing dysplastic (Clark) nevus. Do not interpret this
lesion as a keratotic seborrheic keratosis adjacent to a benign nevus. Follow your intuition and stick with your
first impression that this lesion is strikingly asymmetric in shape, structure, and color and needs to be
excised with highest priority. When analyzing the morphologic features in detail, you will realize that none of
the three criteria mentioned here (see box above) is clearly visible. You do need a bit of imagination to see
them. It does not necessarily matter if you do not see them—what is important is that you recognize this
verrucous melanoma (Breslow index 3.2 mm) and make the right management decisions.
90
2
Pattern analysis
Five melanoma-
Atypical network
Irregular streaks
* Irregular dots/globules
Irregular blotches
Figure 173 Melanoma

Although this is a small lesion, the eccentric area (black circle) indicates the presence of significant
activity. The large hypopigmented featureless area is nonspecific. The differential diagnosis includes a
Clark (dysplastic) nevus and melanoma. There are small foci of pigment network (white circle), irregular
dots and globules (open arrow), an irregular blotch (solid arrow), and a blue-white structure (asterisk).
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 174 Melanoma

This appears to be an easy case of melanoma, although when scanning the entire lesion there is no atypical
pigment network and there are no clear-cut irregular streaks. There are a few dots and globules here and
there throughout the lesion with one asymmetrically located irregular blotch (arrow). The blue-white
structure is extensive, covering most of the lesion. Significant asymmetry of color and structure and multiple
vivid colors are also seen. The dermoscopic diagnosis of melanoma is not difficult if one can recognize the
important high-risk criteria.
91
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 175 Melanoma

This Spitzoid melanoma is a study of asymmetry, irregular streaks (black arrows), and irregular dots and
globules (circle). There are also irregular blotches (white arrow) and blue-white structures.
Five melanoma-
Atypical network
Irregular streaks
Irregular blotches
Figure 176 Melanoma

This is a superficial melanoma with regression with striking asymmetry in shape, structure, and color.
We see (with a bit of imagination) all five melanoma-specific local criteria here. At the end of this chapter,
we are confident that you also will see most of them and therefore have not placed any annotations
on this image. If your pathologist diagnosed this lesion a regressive nevus, we expect you to challenge
it—this is a regressive superficial melanoma.
92
2
Diagnosis of facial melanoma using Asymmetrically pigmented follicles
Pattern analysis
four site-specific melanoma-specific Asymmetrically pigmented follicles are gray circles/
criteria rings of pigmentation distributed asymmetrically
Facial melanomas usually occur in severely sun- around follicular ostia. Sometimes, the gray circles
damaged skin and is called lentigo maligna when an may contain an inner gray dot or circle.
in situ lesion, and lentigo maligna melanoma when
the lesion is invasive. Because of the specific anatomy
of facial skin characterized by numerous folliculo- Rhomboidal structures
sebaceous units and an effaced epidermis, melanomas Rhomboid structures are thickened areas of
on facial skin reveal the following dermoscopic pigmentation surrounding the follicular ostia with a
features. These criteria are present in facial melanomas rhomboidal appearance (a rhomboid is a
in various combinations and as a rule are not found in parallelogram with unequal angles and sides).
non-facial melanomas.
Gray pseudonetwork
Annular-granular structures Gray pseudonetwork describes gray pigmentation
Annular-granular structures are multiple brown or surrounding the follicular ostia formed by the
blue-gray dots surrounding the follicular ostia with an confluence of annular-granular structures.
annular-granular appearance.
93
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Rhomboidal structures
Gray pseudonetwork
Figure 177 Melanoma

The default differential diagnosis of lentigo maligna (melanoma in situ on severely sun-damaged skin)
clinically, dermoscopically, and sometimes also histopathologically is actinic (solar) lentigo. This
diagnostic uncertainty is underlined by the concept of unstable lentigo—an actinic lentigo on the way to a
lentigo maligna. Interestingly, this concept has not been widely adopted, maybe because we are used to
accepting a benign/malignant dichotomy. The lesion depicted here is a lentigo maligna characterized by a
few rhomboidal structures (circle) and hints of a gray pseudonetwork (arrows).
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 178 Melanoma

Annular-granular structures are present in this lesion (arrows). Do not confuse the ostia of the appendages
with the milia-like cysts of seborrheic keratosis. Now check the ostia carefully. Some are totally and some are
partially ringed by thin layers of pigmentation. The dermoscopic diagnosis of asymmetrically pigmented
follicles is made when the rim of pigmentation does not surround the entire ostium. True rhomboidal
structures are not formed yet. The vessels should not be confused with those seen in basal cell carcinomas.
They correspond to the dermal plexus shining through the thinned epidermis.
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2
Pattern analysis
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 179 Melanoma

This lesion shows a variation on the theme of lentigo maligna. Note the asymmetry in structure and color.
There are annular-granular structures that are forming rhomboidal structures. The gray granules of the
annular-granular structures are hard to see, but are there. In addition, quite a few brown globules
representing junctional nests of melanocytes can be seen nicely.
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 180 Melanoma

The asymmetry of color and structure seen here should be more than enough for the novice dermoscopist
to increase his or her index of suspicion of a high-risk lesion. The annular-granular structures make up
rhomboidal structures (arrow). Confluence of rhomboidal structures makes up the gray pseudonetwork
(circle). Biopsy the darker blotch because it could be an area of invasion. Lentigo maligna melanoma—not
lentigo maligna. Do not confuse the follicular ostia with milia-like cysts or comedo-like openings.
95
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 181 Melanoma

The asymmetry of color and structure plus vivid colors, including an overall pinkish hue, should raise
one’s index of suspicion that this is a melanoma. Scan the entire lesion for site-specific, melanoma-
specific criteria. There are very small annular-granular structures, but no asymmetrically pigmented
follicles. There are also multiple subtle rhomboidal structures (arrows) and irregular dots and globules. It is
possible to see melanoma-specific criteria for trunk and extremity melanomas on the head and neck.
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 182 Melanoma

This lesion shows a classic appearance of an early lentigo maligna. There is only a slight asymmetry in
shape. Dermoscopy shows asymmetrically pigmented hair follicles appearing as gray circles (arrows), at
times resembling a target (also called circle within a circle) due to the presence of a dark gray dot within
the gray circle (circle). Today, reflectance confocal microscopy is increasingly and successfully used for
the noninvasive diagnosis of lentigo maligna.
96
2
Pattern analysis
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 183 Pigmented actinic keratosis

For this strikingly asymmetric lesion (in shape, structure, and color), we are raising immediately the red
flag. Closer scrutiny, however, shows that none of the four site-specific, melanoma-specific criteria listed
in the box above are present. There are keratin-filled hair follicle openings that appear white
encompassed by a superficial brown pseudonetwork suggestive of a pigmented actinic keratosis. There
are also rosette-like tiny structures appearing as four white dots, which can be seen only by polarized light
(arrows). The significance of this sign is unclear.
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 184 Solar lentigo

Here the novice will immediately raise the green flag. And closer scrutiny reveals indeed that none of the
four site-specific, melanoma-specific criteria, listed in the box above, are present. The most striking
feature here is the moth-eaten border (see particularly within the circle), a subtle clinical finding that can
be appreciated much better by dermoscopy. In addition, the light-brown pigmentation appears as a
smear (known as the jelly sign).
97
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork

Again we are raising the green flag here as none of the four site-specific, melanoma-specific criteria are
present. There is only a hint of a moth-eaten border in the upper half of the lesion, and there are a few
symmetrically pigmented follicles visible throughout the lesion. Because of the very subtle tinge of gray
color, we recommend annual follow-up of this lesion despite the green flag.
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork

Quickly we are becoming well acquainted with the dermoscopic appearance of a solar lentigo. There are
numerous symmetrically pigmented follicles rather evenly distributed throughout the lesion. And there is
complete absence of all site-specific, melanoma-specific criteria.
98
2
Pattern analysis
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 187 Seborrheic keratosis evolving from an actinic lentigo

The beginner might raise the orange flag here because of the asymmetry in structure and color. Please
note the striking moth-eaten border at the left half of the lesion (circle). In the right lower part of the lesion,
there are several, medium to dark-brown pigmented, regular broad streaks (also called “fat fingers”).
These structures are a rather typical finding for superficial seborrheic keratoses. One needs to see a few
examples of this type of seborrheic keratosis arising from an actinic lentigo before making this diagnosis
with confidence.
Four site-specific
melanoma-specific
criteria
Annular-granular
structures
Asymmetrically
pigmented follicles
Gray pseudonetwork
Figure 188 Pigmented actinic keratosis

The overall architecture of this lesion together with its pinkish coloration is worrisome and we are raising
the red flag. Closer scrutiny reveals a mostly brownish pseudonetwork with only delicate shades of gray
coloration. There are hints of annular-granular-like structures (arrows) and of course we have to take
lentigo maligna into our differential diagnostic considerations. However, histopathology confirmed a
pigmented actinic keratosis. Sometimes even with dermoscopy, the diagnosis of facial pigmented lesions
is rather difficult. 99
Four patterns for acral melanocytic • The pigmentation is located in the ridges when the
lesions pigmented lines are thicker than the nonpigmented
ones and have white dots running along like a
The parallel pattern is found exclusively in
string of pearls. It is not always possible to see the
melanocytic lesions on glabrous skin of palms and
string of pearls.
soles because of the presence of particular anatomic
• The appearance of dermoscopic criteria tends to be
structures inherent to these locations. The
out of focus on acral areas, owing to the thickness
pigmentation may follow the furrows as well as the
of the skin.
ridges of glabrous skin but rarely may also be arranged
• Other clinical data such as the patient’s age and
at a right angle to these pre-existing structures:
history of the lesion are often essential.
• the parallel furrow, lattice-like, and fibrillar
patterns are commonly found in acral benign nevi;
• the parallel ridge pattern is suggestive of Box 2.1 Four patterns for acral melanocytic
melanomas on acral sites. lesions
n Parallel furrow
General dermoscopic principles for n Parallel ridge
evaluating acral lesions n Lattice-like
• First look at the periphery of the lesion n Fibrillar
to determine where the ridges and furrows are.
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2
Pattern analysis
Four patterns for
acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 189 Nevus

This is the parallel furrow pattern of an acral nevus. The dermoscopic hallmark of this lesion is the presence of
several parallel pigmented lines in the sulci (or furrows) of glabrous skin. Please note that the lines in the right
half of the lesion are more pigmented than the ones in the left half. It is not always easy to determine whether
the linear band of pigmentation is in the ridges or the furrows. A helpful clue is that the pigmentation in the
furrows is smaller than the pigmentation following the ridges. See also Figure 199 and 200.
Four patterns for

acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 190 Nevus

This is a stereotypical example of the lattice-like pattern of an acral nevus. It is characterized by a lattice-
like structure formed by a rectangular network of brownish lines punctuated by several whitish dots,
which look like a string of pearls. The whitish dots represent the openings of the acrosyringia situated in
the ridges of the skin. Without specific knowledge of the various dermoscopic patterns of acral nevi, this
benign lesion could easily be misinterpreted as early melanoma.
101
DERMOSCOPY - The Essentials Four patterns for
acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 191 Nevus

This lesion shows a variation of the morphology seen with the parallel furrow pattern, and there are many.
There are only a few linear bands of pigmentation following the furrows of the acral skin. Note the double
contour of the linear pigmentation (arrows) following the furrows in the lower half of this nevus. The
management of acral lesions is strongly influenced by the ability to differentiate the benign parallel furrow
pattern from the malignant parallel ridge pattern.
Four patterns for

acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 192 Nevus

Here is another parallel furrow type of acral nevus with a subtle superimposed globular component.
This lesion has four prominent parallel pigmented lines in the furrows. The bands of pigmentation are
superimposed by few dark-brown to black dots. Between the pigmented bands, there are several tiny
whitish dots arranged like a string of pearls corresponding to the eccrine ducts reaching the surface on the
ridges. Whatever form the pigment takes in an acral nevus, if it is determined to be in the furrows, the lesion
is benign. There can be single lines, single rows of dots and globules, and even double rows of lines or
double rows of dots and globules. Just ensure the pigmentation is not in the ridges. Here we scored this
lesion to be of moderate risk (orange traffic light) because the furrow pattern is difficult to recognize.
102
2
Pattern analysis
Four patterns for
acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 193 Nevus

This lesion provides another example of the lattice-like pattern. It is composed of a grid of pigmented lines
accentuated by numerous whitish dots representing the openings of acrosyringia. The strings of pearls
are in the ridges. The pigmented lines follow the furrows of the acral skin. Thinner pigmented lines are
arranged perpendicularly to the thicker lines to form the characteristic lattice-like pattern—like a ladder.
There are no criteria to suggest that this might be a high-risk lesion.
Four patterns for

acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 194 Nevus

Compared to the lesion in Figure 193, this lattice-like acral nevus is harder to define. It is composed of a
grid of pigmented lines reminiscent in part of a reticular pattern. The presence of multiple colors (light
brown, dark brown, and blue-gray), a poorly defined grid, and few brownish dots and globules makes this
a difficult lesion to classify. However, the advice “if in doubt, cut it out” is not always so easy to follow on
acral sites. If there is no clinical history of growth here, follow-up and self-monitoring is a valid
management option.
103
Four patterns for
acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 195 Nevus

This lesion is out of focus and is a stereotypical example of the fibrillar pattern seen in acral nevi. It is
characterized by numerous short and thin brown lines that not only have a parallel arrangement but also run
oblique to the ridges and furrows of the acral skin. The parallel furrow, lattice-like and fibrillar patterns are
those seen in benign acral melanocytic lesions. Furrow, lattice or fibrillar ¼ benign nevus.
Four patterns for

acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 196 Nevus

This shows a variation of the fibrillar pattern of acral nevus, and it is hard to differentiate this from the
parallel ridge pattern. It is composed of numerous, obliquely arranged, smudged, pigmented, thin, short
lines. There is also a blotch (circle). Numerous light-brown parallel lines are also found in the furrows of
the skin. This lesion is difficult to evaluate; therefore it should be excised. It could easily be mistaken for
the parallel ridge pattern, even by an experienced dermoscopist.
104
2
Pattern analysis
Four patterns for
acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 197 Nevus

This lesion provides a rather typical example of a fibrillar pattern. This pattern is observed particularly in
the pressure areas of the plantar surfaces. Because there is some degree of variation in pigmentation, the
orange flag might be raised here. Still, we felt comfortable not to excise this lesion and recommended
annual follow-up.
Four patterns for

acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 198 Nevus

This is another example of an acral nevus with fibrillar pattern. As in the case above, there is some degree
of uneven pigmentation that also leads to asymmetry in color. Because of this asymmetric pigmentation,
the lesion was interpreted as suspicious, the orange flag was raised, and the lesion was excised. The
histopathologic examination confirmed the diagnosis of benign acral nevus. In hindsight, we could have
well decided to just follow up this lesion with striking fibrillar pattern.
105
Four patterns for
acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 199 Melanoma

This is an acral melanocytic proliferation with a pronounced parallel pattern. Please note that the
pigmented bands are broader than the whitish lines in between. This is suggestive of a parallel-ridge
pattern, and therefore this lesion was excised without any delay. The histopathologic examination
confirmed the diagnosis of an acral-lentiginous melanoma in situ.
Four patterns for

acral melanocytic
lesions
Parallel furrow
Parallel ridge
Lattice-like
Fibrillar
Figure 200 Melanoma

This image shows the periphery of an acral melanoma with a parallel ridge pattern. This asymmetrical
lesion is composed of several brownish-gray, thickened lines in the ridges of the skin. Note the
nonpigmented furrows and hints of strings of pearls in the ridges. Remember that the parallel ridge
pattern is pathognomonic for acral melanoma. The major pitfall is that the parallel ridge pattern might be
misinterpreted as a parallel furrow pattern and the melanoma might be misdiagnosed. Looking at the
lesion clinically will often help one decide what to do.
106
2
Six criteria for diagnosing non- cysts are predominantly found in seborrheic keratoses,
Pattern analysis
melanocytic lesions but they can also be seen in papillomatous dermal
nevi, and rarely a few milia-like cysts are seen in
To diagnose non-melanocytic pigmented skin lesions,
melanomas.
there should be an absence of criteria for melanocytic
lesions (pigment network, globules, streaks,
Comedo-like openings
homogeneous and parallel patterns) and the presence
of criteria considered specific for basal cell carcinoma, Comedo-like openings refer to brownish-yellow or
seborrheic keratosis, hemangioma, or brown-black, irregularly shaped, sharply
dermatofibroma. circumscribed structures. Histopathologically, they
represent keratin plugs within dilated follicular
Blue-gray blotches openings. Due to oxidation of the keratinous
material, they often have a yellowish-brown or dark-
Blue-gray blotches are structureless areas that are brown to black color. Comedo-like openings are
round to oval and often irregular in shape. The color found predominantly in seborrheic keratoses, but they
ranges from brownish-gray to blue-gray. can also be seen in papillomatous dermal nevi.
Histopathologically they represent heavily pigmented, At times it is difficult to differentiate dark comedo-like
solid aggregations of basaloid cells in the papillary openings from the globules seen in melanocytic
dermis of superficial or nodular basal cell carcinoma. lesions.
Blue-gray blotches are a pathognomonic finding in
pigmented basal cell carcinoma, especially when Red-blue lacunae
associated with arborizing vessels and an absence of
Red lacunae appear as sharply demarcated, round to
criteria seen in melanocytic lesions.
oval structures. The color can vary from red, red-blue,
dark-red to black. A whitish color is also often seen in
Arborizing vessels vascular lesions. Histopathologically, red lacunae
Arborizing vessels are discrete, thickened, and represent dilated vascular spaces located in the upper
branched red blood vessels that are similar in dermis. Lacunae with dark-red to black color represent
appearance to the branches of a tree. vascular spaces that are partially or completely
Histopathologically they represent dilated arterial thrombosed. Red lacunae are the stereotypical
circulation that feeds the tumor. Arborizing vessels are criterion of hemangiomas and angiokeratomas.
99% diagnostic of basal cell carcinoma. Rarely they Structures similar in appearance can also be seen in
can be found in intradermal nevi or featureless subungual and subcorneal hematomas.
melanomas.
Central white patch
Milia-like cysts The central white patch diagnostic of
Milia-like cysts are variously sized, white or yellowish, dermatofibromas is a well-circumscribed, round-to-
round structures. Histopathologically, they represent oval, sometimes irregularly outlined, bony-milky-
intraepidermal horn globules, also called horn white area usually in the center of a firm lesion.
pseudocysts, a common histopathologic finding in There are many variations of the morphology of this
acanthotic seborrheic keratosis. Multiple milia-like criterion.
107
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Arborizing vessels characteristic of a basal cell carcinoma are hard to see; therefore this could easily be
mistaken for a melanoma. The blue-white structures and blue-gray blotches also favor a diagnosis of
melanoma, but in this case, it turned out to be a basal cell carcinoma. Blue-white structures are found not
only in melanomas but also in basal cell carcinomas. It is not always possible to differentiate melanoma
from basal cell carcinoma with dermoscopy.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Do not press down hard on a lesion with vessels like this because they may blanch out. This is a classic
dermoscopic picture of a basal cell carcinoma with arborizing vessels (arrow)—like the branches of a
big tree. Rarely amelanotic melanoma looks like this. Other criteria are not needed to make the
dermoscopic diagnosis of basal cell carcinoma.
108
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

There is an absence of criteria in this lesion to diagnose a melanocytic lesion; therefore, look for criteria to
diagnose a non-melanocytic lesion. Arborizing vessels (arrows) and a blue-gray blotch (circle) lead to the
diagnosis of basal cell carcinoma.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is a heavily pigmented lesion, but once the dermoscopist has seen a few like this, the diagnosis is rather
easy. There are different sizes and shapes of blue-gray blotches (arrows) and some prominent but not typical
arborizing vessels. Do not forget that not every morphologic criterion in a given lesion is stereotypical. The
differential diagnosis includes an atypical blue nevus and, more importantly, a nodular melanoma. Keep in
mind that, in nodular equivocal lesions, a histopathologic diagnosis is a must!
109
DERMOSCOPY - The Essentials Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Pink color—beware. Develop a dermoscopic differential diagnosis because not all cases are clear-cut.
There is an absence of criteria to diagnose a melanocytic lesion; therefore, the next step is to consider
which non-melanocytic lesion this is. It does not look like seborrheic keratosis, dermatofibroma, or
hemangioma; therefore, it could be a basal cell carcinoma. There are some foci with ulceration covered
with crusts (arrows), which favor a diagnosis of basal cell carcinoma. The lesion lacks prominent
arborizing vessels, but fine microarborizing vessels are scattered throughout the lesion supporting the
diagnosis of a basal cell carcinoma. Rarely a melanoma could also look like this.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Sometimes the diagnosis is straightforward, as is the case in this basal cell carcinoma. There are delicate
but typical arborizing and microarborizing vessels, and there are many variations of the morphology seen
with blue-gray blotches. Basically there is no differential diagnosis here.
110
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is a stereotypical basal cell carcinoma with arborizing vessels and several blue-gray blotches.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
* Central white patch

Once again, this is a stereotypical example of a basal cell carcinoma with large blotch of blue-gray
pigmentation (circle) and some foci of arborizing vessels (asterisks). In addition, there are, particularly in
the periphery, foci of ulcerations covered with crusts (arrows). Even the dermoscopy beginner will
diagnose this basal cell carcinoma with confidence!
111
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
* Comedo-like openings
Red-blue lacunae
Central white patch

This lesion has three criteria diagnostic of a basal cell carcinoma—ulceration (circles), arborizing vessels
(asterisk), and blue-gray blotches (arrows). For a novice, the pattern of this lesion might seem similar to
the starburst pattern seen in Spitz nevi, but arborizing blood vessels and ulceration are never found in
Spitz nevi.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
* Red-blue lacunae
Central white patch

In this lesion, there are blue-gray blotches, a blue-white structure (asterisk), and sharply outlined blood
vessels (arrows). The differential diagnosis includes basal cell carcinoma, atypical blue nevus, and a
nodular melanoma. The blood vessels (arrows) favor a diagnosis of basal cell carcinoma even though they
are not stereotypical branching vessels.
112
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is another small nodular basal cell carcinoma characterized by numerous clearly visible blue-gray
blotches. There are also hints for arborizing vessels; however, this criterion does not work very well here
as some of the arborizing vessels are present even outside the lesion. Criteria to diagnose a melanocytic
lesion are lacking. Still, the clinical appearance should be sufficient to warrant a histopathologic
diagnosis. Please never forget that hypomelanotic melanomas may deceive sometimes even the expert
dermoscopist.
Six criteria for

non-melanocytic
lesions
* Blue-gray blotches
Arborizing vessels
* Milia-like cysts
Red-blue lacunae
Central white patch

*

Here is another basal cell carcinoma with areas of mini-ulcerations covered by crusts (circle), arborizing
blood vessels, and blue-gray blotches (asterisks). This is a rather clear-cut example of basal cell
carcinoma, but do not forget to develop a dermoscopic differential diagnosis because there will be
surprises from time to time.
113
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This shows another variation of the morphology seen with a basal cell carcinoma. Statistically, this
dermoscopic picture will be a basal cell carcinoma, but amelanotic melanoma can also look like this.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

With this rather striking appearance, this lesion must be malignant, so is it a melanoma or a basal cell
carcinoma? There are gray-blue blotches throughout most of the periphery of the lesion in a ring-like
alignment but no hint of arborizing vessels. The more experienced dermoscopist will recognize the
so-called leaf-like structures (circles), a classic criterion for pigmented basal cell carcinoma, whereas the
beginner might interpret these structures as irregular streaks of a melanoma. Never mind, this lesion
needs to be excised!
114
2
Six criteria for
Pattern analysis
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This small pink lesion has subtle blue-gray blotches, small linear, non-arborizing vessels, and blue-white
structures. Once again the absence of criteria needed to diagnose a melanocytic lesion point toward the
dermoscopic diagnosis of a basal cell carcinoma. As long as it is realized that this lesion is not benign,
dermoscopy has served its purpose. This is a gray-zone lesion and a hypomelanotic melanoma needs to
be excluded.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
* *
* Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Most of this lesion is covered by a crust due to ulceration (circle). There are also small arborizing vessels
(arrows) and blue-gray blotches (asterisks). The pigmentation seen in basal cell carcinomas can be
brown, gray, or blue. It can form well-defined ovoid structures or be indistinct. The more lesions a
dermoscopist diagnoses, the better he or she will understand this basic dermoscopic principle. There are
numerous variations of all dermoscopic criteria.
115
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is a very nonspecific pink lesion. This lesion is as difficult to diagnose for the dermoscopy beginner as
for the dermoscopy expert. The subtle blue-gray blotches and the microarborizing vessels are the only
hint for a basal cell carcinoma. Please note that these criteria could be easily confused with the blue-gray
globules seen in a melanocytic proliferation and with the linear irregular vessels of a melanoma. You have
to manage this lesion as an amelanotic melanoma!
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This heavily pigmented basal cell carcinoma reveals nicely the variation on the theme of blue-gray
blotches. Prominent large blotches are present in the center and small round to ovoid blue-gray blotches
or globules (circles) in the periphery. Arborizing vessels are clearly visible in the nonpigmented parts of
this basal cell carcinoma.
116
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is another pink basal cell carcinoma reminiscent of an amelanotic melanoma. On looking closely,
several foci with leaf-like structures (circles) are noted and allow the diagnosis of basal cell carcinoma to
be made, probably only by expert dermoscopist. The classic criteria for basal cell carcinoma on which we
focus in this dermoscopy primer, namely, blue-gray blotches and arborizing vessels, are not visible in this
basal cell carcinoma.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This nodular heavily pigmented basal cell carcinoma is virtually indistinguishable from a nodular heavily
pigmented melanoma. There are numerous confluent blue-gray blotches present throughout the lesion—a
finding also observed in a nodular melanoma. Please do not forget that in this clinical setting the correct
management decision is more relevant than the pure diagnosis.
117
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

The main dermoscopic criteria in this flat plaque are milia-like cysts (black arrows) and comedo-like
openings (white arrows), which are diagnostic of a seborrheic keratosis. Using these criteria, this is an
easy case to diagnose.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

In this variant of seborrheic keratosis, comedo-like openings (open arrows) and milia-like cysts (solid
arrows) are clearly seen. The dull gray color and the absence of criteria specific for melanocytic lesions
argue against the differential diagnosis of a papillomatous melanocytic nevus.
118
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This lesion shows good examples of well-developed comedo-like openings (arrows) and a few milia-like
cysts. Is there a pigment network in the lower part of the lesion (circle)? No—it is a pseudonetwork formed
by the openings of follicles on the face (site-specific criterion). They are not forming the rhomboidal
structures of a lentigo maligna.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This flat plaque is characterized by multiple comedo-like openings and some milia-like cysts. Looking
carefully at the borders of the lesion, one might think that there is a starburst pattern of a Spitz nevus.
Comedo-like openings and milia-like cysts are as a rule not seen in a Spitz nevus. Perhaps it could be
described as a pseudostarburst pattern.
119
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Sometimes seborrheic keratoses are strikingly asymmetric in shape, structure, and color, and the clinical
image strongly supports this observation. Dermoscopy clearly reveals several comedo-like openings
(circles) and, in addition, few tiny milia-like cysts (arrows). Very rarely comedo-like openings and milia-like
cysts are found also in superficial melanomas, and therefore we raise the orange flag. It is better to shave
one seborrheic keratosis than miss one melanoma!
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
*
Milia-like cysts
* Red-blue lacunae
* * Central white patch
*
Opaque color, milia-like cysts (asterisks), and comedo-like openings (arrows) are seen in this lesion with a
verrucous surface (circle). This lesion should prove easy to diagnose dermoscopically as a seborrheic
keratosis by now.
120
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Compared to the case shown in Figure 226, this is not so easy to diagnose. This lesion is separated by a
few furrows, and there are many comedo-like openings. Do not confuse them with the globules of a
melanocytic lesion. Subtle milia-like cysts are difficult to find (arrows). There are also hypopigmented
areas (circles), which may be seen in seborrheic keratosis. Because of the pronounced blue-white
structures throughout this lesion a diagnostic excision to rule out a melanoma is recommended.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

A clear-cut case of seborrheic keratosis with numerous milia-like cysts and a few comedo-like openings.
Because of these straightforward criteria we are raising the green flag despite the evident asymmetry
of this lesion.
121
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is another stereotypical seborrheic keratosis characterized by numerous comedo-like openings and
only a few milia-like cysts. Criteria for a melanocytic lesion are absent.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

In this flat lesion on the face, there are milia-like cysts (short arrows) and comedo-like openings (long
arrows). In one part of the lesion, the pigmentation seems to form a pigment network (circle), but this is a
pigmented pseudo-network commonly seen on the face. The prominent vessels surrounding the lesion
are a common finding in sun-damaged skin.
122
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is a rather straightforward example of an acanthotic type of seborrheic keratosis characterized by
several comedo-like openings (no annotations because clearly evident) and few milia-like cysts (arrows).
There is also a hint of a blue-white veil and therefore we are raising the orange flag. As evidenced by this
example, there are many variations of seborrheic keratosis. Remember, when in doubt, “shave” it out.
In more elegant words, perform an excisional shave biopsy with subsequent histopathologic examination.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This rather stereotypical example of a seborrheic keratosis is slightly asymmetric in structure because the
several well-developed comedo-like openings are distributed unevenly throughout the lesion. In addition,
the clinical image displays well the stuck-on appearance of a classic seborrheic keratosis. The only
relevant differential diagnosis here is a benign papillomatous dermal nevus and therefore we are raising
the green flag.
123
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This seborrheic keratosis is composed of a more or less diffuse pigmented area with a grayish color and
numerous reddish dots reminiscent of dotted vessels. Classic comedo-like openings and milia-like cysts
are not visible even to the expert dermoscopist. Based on clinico-dermoscopic correlation, we are
confident that this is superficial seborrheic keratosis and raise the green flag. Please remember if you are
not so confident and want to rule out a lentigo maligna or a pigmented basal cell carcinoma, perform a
diagnostic biopsy.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Despite the striking asymmetry of color, structure, the presence of multiple milia-like cysts and a few
comedo-like openings in this lesion are virtually diagnostic of a seborrheic keratosis. However, because of
the two large black blotches we raised the orange flag and performed a shave biopsy to rule out an
unusual verrucous melanoma.
124
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is a seborrheic keratosis probably arising from a solar lentigo. Please note the many solar lentigines
on moderately to severely sun-damaged skin surrounding this seborrheic keratosis. There are few
comedo-like openings (circle) and several so-called fat fingers on the upper pole of this lesion. The latter
could be interpreted as irregular streaks and lead one astray to the diagnosis of a superficial melanoma.
Nevertheless, we raised the green flag as we were confident about the diagnosis of seborrheic keratosis.
However, you are in charge of your patients and if you are not sure, then shave it out! We cannot
overemphasize this basic principle.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is a rather straightforward seborrheic keratosis despite the lack of the classic criteria like milia-like
cysts and comedo-like openings. This lesion is characterized by a variation on the theme of a brown
pseudonetwork and several fat fingers are sticking out at the periphery. We are raising the green flag here
and with a bit of experience you will also confidently do the same in a morphologically similar lesion.
125
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is a very unusual irritated seborrheic keratosis with bluish and pink coloration lacking any classic
criteria for seborrheic keratosis. In a lesion like this, you have to be very objective and conclude that there
is asymmetry in structure and color as even dermoscopically there is no hint of any diagnostic category.
And remember, although the diagnosis is very difficult here, the management is pretty straightforward. A
deep shave biopsy or an excisional biopsy with a small margin—both will do the job! Always err on the
side of caution and excise equivocal lesions with a confusing dermoscopic picture.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This shows yet another variation of the morphology seen in seborrheic keratosis located on the face. Are
the multiple light-yellow circles comedo-like openings or follicular openings? It is hard to make the
differentiation, but we favor comedo-like openings. Clinically, it looks like a seborrheic keratosis, and with
dermoscopy, there are no high-risk criteria suggestive of lentigo maligna.
126
2
Six criteria for
Pattern analysis
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is another example of a seborrheic keratosis lacking the classic dermoscopic criteria, namely,
milia-like cysts and comedo-like openings. The differential diagnosis of this superficial reticular type of
seborrheic keratosis represents a benign reticular nevus. The sharp demarcation of the reticulation at the
periphery here favors a seborrheic keratosis; in melanocytic nevi, the network fades out toward the
periphery. Obviously this distinction is merely an academic exercise. We can easily raise the green flag
here.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is the last case in a series of seborrheic keratoses and obviously we like to share an equivocal example
with you. Similar to Figure 233, this seborrheic keratosis is composed of a diffuse pigmented area with blue-
gray blotches and numerous reddish dots reminiscent of dotted vessels. Typical comedo-like openings and
milia-like cysts are lacking. Again based on clinico-dermoscopic correlation, we are confident that this is
seborrheic keratosis. However, because of the prominent blue-gray blotches and the pinkish peripheral
coloration, we raise the red flag. We would not like to miss a melanoma or a pigmented basal cell carcinoma!
127
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch
Figure 241 Hemangioma

This is a classic hemangioma with multiple red lacunae. They are well-demarcated, reddish, round-to-
polygonal structures that correspond to the dilated vessels in the upper dermis. White color is commonly
found in hemangiomas; in this case, it has a reticular pattern. There is no doubt of the dermoscopic
diagnosis in this case.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
* Red-blue lacunae
Central white patch

This vascular lesion is characterized by red (asterisks) and purplish (arrows) lacunae. It is possible to
confuse the blue to purplish color with a blue-white structure. It is unusual to find two colors in a
hemangioma. If in doubt, cut it out.
128
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is another stereotypical example of cherry (senile) hemangioma and has numerous well-
circumscribed red-blue lacunae (arrows). Remember that, to diagnose the lacunae, they should have
sharp borders. They should be clear and not out of focus or blurred.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
* Red-blue lacunae
*
Central white patch

This hemangioma displays a diffuse blue-white color that mimics blue-white structures. Even closer
scrutiny does not reveal well-developed and clear-cut red-blue lacunae, although in hindsight of the
histopathologic diagnosis of a hemangioma with prominent fibrosis, red-blue lacunae (circles) are present.
The black areas (asterisks) represent thrombosed vascular spaces. Because of the equivocal
dermoscopic appearance, we raised the orange flag and excised this lesion.
129
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch
Figure 245 Fibroangioma

This is a fibroangioma characterized by a diffuse reddish-whitish color, which is the hallmark of the lesion.
There are several red lacunae throughout the lesion. The fenestrated whitish lines represent fibrosis
encompassing the angioma lobules. Pyogenic granuloma, Kaposi’s sarcoma, and amelanotic melanoma
could have a similar dermoscopic appearance; therefore, the red flag has been raised and the lesion was
excised.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is an example of hemangioma characterized by dark-red to blue-black lacunae encompassed by
whitish lines forming a sort of fenestrated pattern. This specific pattern is commonly observed in a
histopathologic variant of hemangioma called lobular capillary hemangioma. Quite often, dark-colored
hemangiomas mimic melanoma or melanoma metastasis clinically. Dermoscopy usually is very helpful in
making the correct diagnosis. Still we raised the orange flag here and excised the lesion.
130
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
* Milia-like cysts
Red-blue lacunae
Central white patch

This hemangioma is partially thrombosed. The reddish-black areas represent thrombosed vascular
spaces (asterisk) and not the blotches of a melanoma.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This hemangioma is characterized by red-blue lacunae with a predominantly bluish color. The peripheral
light-blue halo indicates deeper involvement of the hemangioma in the dermis.
131
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is another classic example of cherry hemangioma. In contrast to Figure 241, the coloration is darker.
The fenestrated whitish pattern reflects the fibrosis encompassing the hemangioma lobules. In a case like
this, even the beginner can make the diagnosis of a hemangioma. There is no need to perform a biopsy in
a clear-cut example like this one.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Although the expert dermoscopist favors here a thrombosed hemangioma, there is no doubt that this
lesion is worrisome. There are dark-red to black lacunae corresponding to the thrombosed areas and
bluish-white areas most probably corresponding to dermal fibrosis. The differential diagnosis here
includes an ulcerated melanoma and an ulcerated basal cell carcinoma. A diagnostic excision is definitely
warranted.
132
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This lesion shows a variation of the morphology that can be seen with a partially thrombosed and fibrosed
hemangioma. It is characterized by numerous tiny red-blue to purplish-black lacunae throughout the
lesion. In addition, a diffuse blue-whitish hue is present. There are many faces of vascular lesions, and the
red to purplish color is key to making the diagnosis. But remember, if in doubt, cut or shave it out. We are
raising the orange flag here.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch
Figure 252 Pyogenic granuloma

This is a vascular lesion because it has large red lacunae. Numerous telangiectasias are also present
(arrow). The diagnosis of a pyogenic granuloma can be made only on clinical or histopathologic grounds
because precise differentiation from a hemangioma is difficult with dermoscopy. Remember that
amelanotic melanoma, the great masquerader, is always in the differential diagnosis of a pyogenic
granuloma.
133
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
*
Red-blue lacunae
Central white patch

*
Figure 253 Kaposi’s sarcoma

The dermoscopic appearance of this vascular nodule is nonspecific and similar to the pyogenic
granuloma and the fibroangioma shown in Figure 245. There are red lacunae and whitish areas of fibrosis
(asterisks). Important historical and clinical data might be needed to help diagnose certain vascular-
appearing lesions.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

As in the previous figures, this vascular lesion exhibits red-blue lacunae with pronounced whitish areas of
fibrosis. The dermoscopic differential diagnosis includes fibroangioma, fibrosing pyogenic granuloma,
and Kaposi’s sarcoma. As a rule, the dermoscopic aspect of a lesion should be part of the overall clinical
assessment of the patient. This is another basic dermoscopic principle that cannot be overemphasized.
Sometimes it is wise to raise the red flag unnecessarily as happened here.
134
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch
Figure 255 Dermatofibroma

This stereotypical dermatofibroma with a central white patch (asterisk) is surrounded by a very subtle
pigment network (arrows). Dermatofibromas are one of the few non-melanocytic lesions that can have a
pigment network.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

In this dermatofibroma, the central white patch predominates. Light pigmentation, but not a network, can
be seen at the periphery. Palpating this firm papule will help in making the diagnosis. There are numerous
variations of the white patch seen in dermatofibromas.
135
Six criteria for
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This dermatofibroma has a reticular depigmentation (circle), which is a variation of the central white patch.
A very subtle pigment network can also be seen at the periphery (arrows). A reticular white color is
commonly seen in dermatofibromas.
Six criteria for
*
non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
* Milia-like cysts
Red-blue lacunae
Central white patch

This is another example of classic dermatofibroma with a central white patch and a fine typical pigment
network at the periphery (asterisks). Do not diagnose this as seborrheic keratosis just because milia-like
cysts (arrows) can be seen.
136
2
Pattern analysis
Six criteria for
non-melanocytic
lesions
* Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

This is a stereotypical example of dermatofibroma with a central white patch (asterisks) and a well-
detectable but subtle pigment network at the periphery. In a case like this, the beginner will have no
problems to raise the green flag and also to diagnose this lesion as dermatofibroma. Of course, palpating
this lesion will help in the diagnostic process.
Six criteria for

non-melanocytic
lesions
Blue-gray blotches
Arborizing vessels
Milia-like cysts
Red-blue lacunae
Central white patch

Sometimes dermoscopy does not support the diagnosis of dermatofibroma as is the case in this pink
lesion here. There are numerous dotted vessels rather evenly distributed throughout the lesion. The
differential diagnosis includes a Spitz nevus and an amelanotic melanoma. Even palpation does not help
here as a desmoplastic melanoma may give the same result upon palpation. Beware pink lesions, raise
the red flag and perform a diagnostic excision.
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Common clinical scenarios
Side-by-side comparisons of similar-appearing lesions that
3
are benign or malignant
Introduction Pediatric scenario

When you examine a skin lesion with dermoscopy, it General principles
might be obviously benign or malignant. There is also • Melanoma in childhood is exceedingly rare and the
a gray zone of equivocal lesions. Gray-zone lesions great majority of melanocytic skin lesions in
will commonly be encountered by the novice prepubertal children are benign and do not require
dermoscopist. To help deal with this common any special attention. The dermoscopic criteria of
situation, we offer a few suggestions. Learn the basics, childhood nevi are the same as in other age
practice the technique as often as possible, and groups, but in most cases, childhood nevi reveal
develop a dermoscopic differential diagnosis. a globular pattern.
You have to be able to think things through • The most problematic skin tumors in the pediatric
logically, weighing the pros and cons for each criterion patient are large to giant congenital melanocytic
or pattern that you see. Coming up with a tentative nevi and atypical Spitz tumors.
dermoscopic diagnosis, or in many cases, a • Large to giant congenital nevi represent the
dermoscopic differential diagnosis, is the end of the most important risk factors for melanoma
process. in prepubertal children, although the risk is
For example, are the round to oval yellow dots and still low (<1%). Because melanoma associated
globules you see the milia-like cysts of a seborrheic with large to giant congenital melanocytic
keratosis or the follicular ostia of a melanocytic nevi often develops deep in the dermis or
lesion? What a difference that distinction could make. in the central nervous system, dermoscopy is
You could be dealing with a seborrheic keratosis or a of limited benefit in the early diagnosis of
lentigo maligna. Are those the brown dots and melanoma.
globules of a melanocytic lesion, or the pigmented • The risk for melanoma in small to medium
follicular openings of a seborrheic keratosis? You congenital melanocytic nevi is not established, but
notice that the lesion has some blood vessels. Are they they should be kept under regular surveillance.
the thickened branched vessels of a basal cell Biopsy is indicated in the case of significant atypical
carcinoma, or the irregular linear vessels that can be structural changes.
found in melanomas? • There are no definitive guidelines about the
We regret to inform you that you will encounter management of Spitz nevi, and there are
difficult lesions—lesions that even the most controversies about whether to follow up or excise
experienced dermoscopist will not feel confident with. these nevi. However, flat pigmented Spitz nevi
That is the state of the art as it exists today. There are (commonly also called Reed nevi) with a
infinite variations of criteria, patterns, and lesions. The stereotypical dermoscopic starburst pattern,
scenarios in this final chapter demonstrate the appearing below the age of puberty, can be
dermoscopic thought process we employ. Focus your managed conservatively and can be regularly
attention, use what you have learned in the first two followed up as there is a well-documented
chapters of the book, and you will find that you will tendency of involution.
learn and grow with each case. Do not be intimidated • Atypical Spitz tumors and rare childhood
by what you see. We guarantee that you can master melanomas commonly represent as rapidly
this technique. You will develop your own style of growing, pigmented or nonpigmented nodules.
dermoscopic analysis and find that dermoscopy will Immediate excision of any lesion showing these
become an essential part of your practice. You will not clinical characteristics is indicated.
be able to practice without it!
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Figure 261 Congenital nevus

This congenital nevus revealing some irregularity of color and structure is located on the forearm of a
3-year-old child. Closer scrutiny of the central area displays large and somewhat angulated brown-gray
globules (also called cobblestone pattern), which are surrounded by smaller brown globules;
characteristic is also the presence of numerous terminal hairs showing either a perifollicular
hyperpigmentation or hypopigmentation. Despite the worrisome aspect of this lesion, we raise with
confidence the green flag and recommend annual follow-up.
Figure 262 Melanoma in situ arising in a small congenital nevus

While melanoma before puberty is very uncommon, the risk increases after puberty. This lesion is located
on the shoulder of a 15-year-old girl, who noticed a recent change of color in the pre-existing nevus
characterized by numerous brown-gray globules resembling cobblestones (arrows). Dermoscopically, the
melanoma appears as an irregular blue-gray blotch (circle) in paracentral location of an otherwise
regularly pigmented globular (cobblestone) nevus.
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Figure 263 Pigmented Spitz nevus (Reed nevus)
This is a stereotypical example of a flat pigmented Spitz nevus located on the thigh of a 3-year-old girl.
The dermoscopic hallmarks of a pigmented Spitz nevus (commonly also called Reed nevus) are regularly
distributed peripheral streaks that arise from a heavily pigmented black to blue-gray center. During follow-
up, these nevi enlarge symmetrically until the disappearance of peripheral streaks indicates stabilization
of growth. At this stage, the nevus reveals a homogeneous black-bluish pigmentation. We are raising here
the orange flag appreciating that the management of these lesions is complex.
Figure 264 Flat nonpigmented Spitz nevus

This flat or plaque-like reddish nevus is located on the abdomen of a 6-year-old boy. Dermoscopically,
nonpigmented Spitz nevi display regularly distributed dotted vessels over a milky-red background as
evidenced by this image. Typically a reticular depigmentation can be seen appearing as white net-like
lines between the dotted vessels. Because of the lack of both general guidelines and well-documented
cases of involution, nonpigmented Spitz nevi should be excised even in children. Remember our slogan
“pink lesion beware” and raise the red flag.
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Figure 265 Atypical nonpigmented Spitz tumor

This reddish nodule was located on the cheek of an 11-year-old girl and revealed a history of rapid growth
within a few months. Despite a brown residual pseudonetwork (circle), the nonpigmented nodule lacks
any specific pattern and exhibits only pink to red homogeneous areas. No doubt we have to raise the red
flag here. The lesion was excised and revealed also histopathologically highly conflicting features.
The final histopathologic diagnosis was atypical Spitz tumor and follow-up after 3 years revealed no
recurrence.
Figure 266 Melanoma

This is a melanoma on a 14-year-old child. It has melanoma-specific criteria—a blue-white structure
(asterisk), which is easy to see, subtle streaks (square), and irregular dots and globules (circle). Young
patients do get melanoma and die from their disease, so it is necessary to increase one’s index of
suspicion for pediatric patients.
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Figure 267 Common nevi
This 7-year-old boy reveals some nevi on his back. All nevi are characterized by a uniform pigmentation
and by a globular pattern. These nevi do not require any special further attention, and we are raising the
green flag with confidence here.
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Black lesions • The differential diagnosis of a single black macule
or papule could be melanocytic or nonmelanocytic,
General principles benign, or malignant.
• Clinically, black color is not always ominous. • What should be done on finding a black lesion?
• Black color with dermoscopy is also not always Check it out with dermoscopy before making
ominous. another move.
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Figure 268 What is your clinical diagnosis?
This clinically nonspecific black lesion looks like that in Figure 269. There is no way to know for sure which
is benign and which is malignant. What should be done? Cut it out or check it out? (see Figure 270.)
Figure 269 What is your clinical diagnosis?

This clinically nonspecific black lesion looks like that in Figure 268. There is no way to know for sure which
is benign and which is malignant. What should be done? Cut it out or check it out? (see Figure 271.)
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Figure 270 Melanoma

Step 1—is it melanocytic or nonmelanocytic? It is a melanocytic lesion because there are streaks at the
periphery (arrows). Step 2—is it benign or malignant? Can melanoma-specific criteria be identified?
The blue-white structure (asterisk) and irregular blotches (circles) are enough to warrant excision as soon
as possible.
Figure 271 Nevus

A sigh of relief. This is a benign nevus because of the symmetry of color and structure. It has a typical
pigment network (circle), regular dots and globules (arrows), but only one melanoma-specific criterion—a
subtle blue-white structure. The dots and globules at the periphery indicate an actively growing lesion.
This is the type of pigmented skin lesion that needs clinical and dermoscopic follow-up.
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*
*

Is there a blue-white structure (asterisks) here? Maybe there are some subtle streaks at the periphery of
the lesion. And there might be a few comedo-like openings (arrows). So, this lesion has melanoma-
specific criteria and criteria seen in a seborrheic keratosis. Sometimes an acanthotic seborrheic keratosis
may be heavily pigmented and nearly devoid of any typical criteria. In a case like this, the expert raises the
green flag and the beginner might be more cautious and raise the orange flag and excise the lesion.
Remember, if in doubt, cut or shave it out.
*
*
Figure 273 Spitz nevus

The differential diagnosis for this Spitzoid appearance should include pigmented Spitz nevus (also called
Reed nevus) and melanoma. There is a central rather subtle blue-white structure (asterisks) and
symmetrically oriented streaks around the lesion. These features favor the diagnosis of a Spitz (Reed)
nevus. If a lesion like this one is found in a patient after puberty, a diagnostic excision needs to be
performed. Because this lesion was located on the dorsal hand of an adult woman and, in addition, there
was also a history of rapid growth, this lesion was excised.
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Inkspot lentigo developing melanoma. Do not forget to do a
comprehensive skin examination to look for high-
General principles risk pigmented skin lesions.
• Clinically and dermoscopically inkspot (or • Inkspot lentigines are usually located on the upper
reticular) lentigines have a very characteristic trunk and extremities and are surrounded by
appearance. regular or large sunburn freckles.
• Typically, an inkspot lentigo is black and sharply • On seeing an “inkspot lentigo,” try not to miss
demarcated with a bizarre-looking pigment seeing the presence of any melanoma-specific
network filling the lesion. There is an absence of criteria.
other criteria. • If in doubt, cut or shave it out.
• Individuals with inkspot lentigines commonly have
fair skin, light hair, and light eyes and are at risk of
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Figure 274 Inkspot lentigo
This is a variation of the morphology seen in an inkspot lentigo characterized by a bizarre pigment
network. There is also a large homogeneous area with a gray color representing melanophages in the
papillary dermis.

This is a stereotypical inkspot lentigo. The network is commonly black.
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A third variation of the appearance of inkspot lentigo. The clinical appearance, dark color, bizarre shape of
the pigment network, and absence of other criteria suggest the correct diagnosis.

This picture is worrisome because of the asymmetry of color and structure, the irregular dots and
globules, and the irregular blotch. It is not wrong to biopsy a lesion that looks like this.
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Figure 278 Clark (dysplastic) nevus
The quality of the pigment network is suggestive of a reticular type of Clark (dysplastic) nevus. The
pigment network is atypical, and the color is blotchy. Therefore, excision or digital follow-up is
recommended.
* *
Figure 279 Melanoma

This lesion is black with a pigment network, but these are the only features this melanoma has in common
with an inkspot lentigo. This lesion has prominent melanoma-specific criteria—an atypical pigment
network (circles), irregular dots and globules (asterisks), and rather typical streaks (arrows).
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Blue lesions • It is imperative to develop a complete differential
diagnosis for blue lesions.
General principles • If you see a lesion with blue color but it also has
• Blue color can be seen in benign and malignant other criteria, it should be evaluated like any other
lesions. They are not all blue nevi. lesion.
• Blue color indicates that melanin is deep in the • Blue lesions can be tricky. If in doubt, do not
dermis. hesitate—cut it out.
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Figure 280 Nodular melanoma on the face
This rather expophytic, ulcerated and hemorrhagic tumor shows structureless blue-white color in the
absence of any specific criteria of a melanocytic or nonmelanocytic tumor. Although structureless blue
color may be seen also in blue nevi, the irregular distribution of colors together with the ulceration and
bleeding represents a high-risk dermoscopic image and must be removed. In fact, it turned out to be a
nodular melanoma.

Another example of a blue-whitish ulcerated nodule prompting us to immediately raise the red flag. There
are evident focused vessels and some isolated gray globules as well as a large central ulceration. The
experienced dermoscopist might favor a basal cell carcinoma but will insist on a diagnostic excision with
high priority because a nodular melanoma cannot be ruled out with certainty.
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Figure 282 Melanoma

One’s first opinion might be that this is a basal cell carcinoma because of the ulceration (asterisk) and
vessels (white arrows). Scan the lesion for all criteria. It actually has dots and globules (circle), so it is
melanocytic. Now it is looking like a melanoma because of the blue-white structure, asymmetrically
located irregular dots and globules, and irregular streaks (black arrow). This lesion therefore needs a
diagnostic excision with a high-level of priority. The dermoscopic picture will help in planning the surgical
approach. It is important not to shave through this invasive melanoma.

This lesion is remarkably similar to that shown in Figure 282. Features include ulceration (asterisk), blue-
white structures (circles), and a few irregular dots and globules (arrows). This lesion is melanocytic by
definition if the rules are strictly followed, although it turned out to be a basal cell carcinoma. The
important point is that this dermoscopic picture needs a diagnostic excision with a high-level of priority.
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Figure 284 Melanoma metastasis
The differential diagnosis of this bluish nodule in the axilla is a blue nevus on one hand and a nodular
melanoma or a melanoma metastasis on the other. No doubt the history of the given tumor is of high
importance; blue nevi usually have a very stable history in contrast to melanoma or melanoma metastasis,
which grow rapidly. In this case, the nodule developed rapidly in a patient with a previous primary
melanoma. This along with the dermoscopic aspect should always lead to biopsy—here it was a
melanoma metastasis.
Figure 285 Blue nevus

This is a good example of a blue nevus with relatively homogeneous blue color. It is dry and scaly
(asterisk) with milia-like cysts (arrow). Do not forget that the differential diagnosis includes nodular and
cutaneous metastatic melanoma. The entire clinical picture will help one decide on the management of
this lesion.
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Reticular lesions • Reticular pattern ¼ significant areas with pigment
network.
General principles • Is the pigment network typical or atypical?
• Take a bird’s-eye (global) view of the entire lesion • What other criteria are there to make the
to get a first impression. dermoscopic diagnosis?
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Figure 286 Melanoma in situ
Surprisingly this turned out to be an in situ melanoma. It does not look that worrisome. There is enough
pigment network to say it has a reticular pattern, and the pigment network is slightly atypical. The subtle
irregular streaks (circle) push this lesion over the edge to be malignant. Statistically, a lesion with this
dermoscopic picture would not be a melanoma, but a Clark (dysplastic) nevus. It is suspicious enough to
warrant a histopathologic diagnosis.

The pigment network fills most of this lesion. It has more of a reticular pattern than that shown in
Figure 286. The pigment network and dots and globules are questionably atypical, but not strikingly
worrisome. Differentiate this benign nevus from the in situ melanoma in Figure 286. Here the network lines
are thin and fade out at the periphery, in contrast to the previous case.
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The pigment network is slightly atypical in this lesion because the line segments are thicker, branched,
and broken up. There are no other melanoma-specific criteria. Do not confuse the central area of
hypopigmentation with a blue-white structure. Statistically, this picture is seen most often with
Clark (mildly dysplastic) nevi.
*
*

This lesion looks more ominous with a reticular pattern forming a starburst pattern. There are streaks at all
border points along the periphery (arrows). This favors the diagnosis of a Spitz nevus. Blue-white
structures can be seen in both Spitz nevi and melanomas. Melanoma-specific criteria include irregular
dots and globules (asterisks) and irregular blotches (circle). Excise this lesion.
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Figure 290 Melanoma
Imagination is needed to in situ the streaks and atypical pigment network that classify this as a reticular
pattern. The dermoscopist should realize that this is a high-risk lesion because of the clear-cut asymmetry
of color and structure. As is the case here, an early in situ melanoma may be hard to diagnose.
Figure 291 Melanoma

This bizarre dermoscopic picture shows areas with very atypical pigment network (circle), irregular streaks
(arrows), and irregular dots and globules in the left lower part of this lesion. Never tell a patient that they
definitely have a melanoma based on the dermoscopic picture, no matter how ominous it looks. The result
of the histopathologic examination sometimes may surprise you.
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Spitzoid lesions • Asymmetrical Spitzoid pattern ¼ rule out
melanoma.
General principles • The stereotypical starburst pattern is seen more
• Spitzoid means similar in appearance to a starburst frequently than the globular pattern, which is more
pattern. common than the nonspecific Spitzoid pattern.
• Spitzoid differential diagnosis includes Clark
(dysplastic) nevus, Spitz nevus, and melanoma. Caution
• Spitzoid morphology comprises a light-dark or blue Deaths have occurred secondary to metastatic “Spitz”
central area and dots and globules or streaks at the nevi that were in reality melanomas. Excise the vast
periphery. majority of Spitzoid lesions. It is better to be safe than
• Symmetrical Spitzoid pattern ¼ benign lesion. sorry.
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*

This is a classic symmetrical Spitzoid pattern. In the center of the lesion, there is a subtle blue-white
structure (asterisk). The rim of dots and globules at all points along the periphery of the lesion allows this
dermoscopic diagnosis. On looking carefully, there are also some streaks at the periphery.
Figure 293 Melanoma

Compared to the lesion shown in Figure 292, this lesion demonstrates significant asymmetry of color and
structure with several melanoma-specific criteria. Why then is this Spitzoid? There is subtle central
blue-white structure with irregular dots and globules and streaks at the periphery. They are trying to form
a starburst pattern, but the criteria are not at all evenly distributed at the periphery of the lesion. This
constellation of findings raises the red flag and the lesion was diagnosed histopathologically as
melanoma.
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It is important to recognize symmetry and asymmetry in Spitzoid lesions. This lesion is very symmetrical,
with subtle radially oriented streaks (arrows) at all points along the periphery of the lesion. Remember the
criteria are not always easy to see, so practice dermoscopy as much as possible to be able to see subtle
patterns. The central blue-white structure is commonly found in Spitz naevi.
Figure 295 Melanoma

It is necessary to stretch one’s imagination to call this a Spitzoid nevus. It does fit the pattern because
there is a central blue-white structure (asterisk) and there are asymmetrically located streaks (arrows) at
the periphery. The pigment network is very atypical. It does not matter whether this is called Spitzoid or
not—it could be a melanoma and should be excised.
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Here is another rather classic symmetrical starburst pattern. If this pattern is etched on the mind, it will be
recognized immediately. This Spitz nevus has a darker central blotch partially covering a blue-white
structure, and symmetrically located streaks (arrows) at all points along the periphery of the lesion.
Figure 297 Melanoma

This is a Spitzoid melanoma with a centrally located blue-white structure (asterisk), a horseshoe-shaped
dark blotch (solid arrows), and asymmetrically located streaks (open arrows) at the periphery. Pink color—
beware.
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Special nevi • Special nevi can be clinically easily diagnosed, and
in most cases, dermoscopy simply confirms the
General principles clinical diagnosis.
• Special nevi are defined as benign melanocytic nevi • A special history of injury or incomplete surgical
that exhibit a rather specific constellation of removal provides further clues for the diagnosis of
features resulting often in a targetoid or iris-like traumatized and recurrent nevi.
appearance. • Special rules have been established for the
• The group of nevi with special features includes management of special nevi.
Sutton nevi, Meyerson nevi, traumatized nevi,
recurrent nevi, combined nevi, and cockade nevi.
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Figure 298 Sutton nevus (halo nevus)
Sutton nevi, also termed “halo nevi,” are benign melanocytic nevi clinically characterized by a peripheral
rim (halo) of depigmentation. Dermoscopically, the central nevus component typically reveals a benign
globular, structureless brown, or reticular pattern, whereas the peripheral ring is white and structureless. If
appearing during young adolescence, no further treatment is warranted and we raise the green flag. Look
carefully at the other nevi of your patient. Usually you will find a few more Sutton nevi.
Figure 299 Meyerson nevus

Meyerson nevus, also termed “eczematous nevus,” is characterized by the development of an
eczematous halo around one or more pigmented nevi (left). Because the eczematous inflammation results
in an unclear clinical and dermoscopic appearance, re-evaluation after a short cycle of topical antibiotic or
steroid treatment is recommended. In the case of persisting or recurrent inflammation or if atypical
features are present, excision is recommended. In this case, the halo resolved following a short term of
topical steroid treatment and therefore the lesion was not excised.
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Figure 300 Hemosiderotic targetoid nevus

Traumatized nevi, also termed “irritated or hemosiderotic targetoid nevi,” are characterized by the sudden
onset of a peripheral purple rim after injury to a pre-existing nevus. Typically, traumatized nevi are nodular or
papillomatous and patients refer to a recent history of injury. Dermoscopically, the central nevus component
appears blurred and is often covered by a hemorrhagic crust typically surrounded by a purple structureless rim
as is the case here. Re-evaluation after a couple of weeks is recommended to reassess the disappearance of
the peripheral purple halo. Please do not forget that sometimes also melanomas may be traumatized.
Figure 301 Recurrent nevus

Recurrent nevi are also often referred to as melanoma simulators both dermoscopically and
histopathologically. They occur frequently in scars shortly after incomplete surgical removal or following a
trauma. By dermoscopy, recurrent nevi exhibit centrally located irregular dots/globules and streaks or, as in
this lesion, also an irregularly outlined brownish-black blotch. In the cases with a confirmed previous
histopathologic diagnosis of a nevus, no further treatment is warranted, while in all other cases, excision is
mandatory. Here the pigmentation occurred after an injury and the lesion was therefore excised posthaste.
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Figure 302 Combined nevus
Combined melanocytic nevi are defined as the histopathologic presence of two different types of benign
melanocytic proliferations. They often have a clinically targetoid appearance (see also Figure 300).
Because of the presence of two populations of nevus cells, color variegations or more than one structure
can be present. Dermoscopically, the most classic type is that of a blue nevus and a congenital nevus as
demonstrated here. Please note the light-brown nearly structureless area on the right and the
homogeneous blue-whitish roundish area on the left. Because combined nevi are rare, excision is
generally recommended to rule out a melanoma within a pre-existing nevus.
Figure 303 Cockade nevus

Cockade nevi are benign nevi characterized by a central pigmented, often papular portion that is
surrounded by an inner depigmented and outer pigmented rim. The central portion typically shows a
globular or cobblestone pattern, whereas the outer pigmented rim often shows a reticular pattern as
nicely displayed here. Cockade nevi are benign and no further treatment is required. Of course, in case
you are not familiar with this specific type of nevus, you may raise the orange flag and, depending on the
specific location, a diagnostic excision or a second opinion consultation may be the way to go.
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Multiple Clark (dysplastic) nevi • The “ugly duckling” pigmented skin lesion seen
both clinically and with dermoscopy warrants a
General principles histopathologic diagnosis.
• Examining multiple nevi with dermoscopy is cost- • If a patient has multiple high-risk-looking lesions
effective and provides information about whether a with dermoscopy, excise one or two to make a
patient has multiple high-risk or banal nevi. dermoscopic-pathologic correlation.
• Most patients with multiple nevi have low-risk • The true number of melanomas is small compared
lesions, but this can be confirmed by checking to the number of patients with multiple dysplastic
them out with dermoscopy. nevi. The vast majority do not need to be excised
• Ask patients whether they have any new or but can be followed using digital systems to look
changing nevi. Never ignore the patient’s history. for significant changes over time.
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Figure 304 Multiple nevi
This is a stereotypical example of a person with multiple nevi. Clinically they look low risk, but he could
have a melanoma. It is possible to examine most of these lesions rapidly with dermoscopy and obtain
clues to point to high-risk lesions that do not look high risk clinically. These are usually the early
melanomas that offer patients their best chances of survival. Dermoscopy opens up a new world of colors
and structures that help in managing this common, difficult and serious problem (see Figures 305–308).
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*
* *

Here is an example of a dysplastic nevus from the individual shown in Figure 304. Multifocal
hypopigmentation (asterisks), atypical pigment network (circles), and irregular dots and globules (arrows)
are seen. In the realm of dysplastic nevi, dermoscopic findings do not always correlate with pathology.
Very worrisome lesions often turn out to be mildly dysplastic, whereas relatively featureless lesions may
be revealed histopathologically to be severely dysplastic.

A similar pattern of dermoscopic criteria to those observed in Figure 305 can be seen in this nevus. The
irregular blotches (arrows) point to a potentially more high-risk dysplastic nevus. Excision and digital
follow-up examination are two ways to manage this lesion.
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An “ugly duckling” lesion that stands out has still not been found in this patient, who appears to have
relatively similar-looking nevi. Which one should be excised to make a dermoscopic-pathologic
correlation?
Figure 308 Melanoma

Here is the ugly duckling, however. This reddish, relatively featureless lesion differs from the others. Note
the multifocal hypopigmentation (arrows) verging on regression areas and atypical pigment network.
Excision is mandatory. Dermoscopy reveals high-risk lesions like these, which can otherwise be easily be
overlooked if the patient is examined with the naked eye or using the typical magnification clinicians use.
Melanomas will be missed less often if dermoscopy is mastered.
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Follow-up of melanocytic lesions • There are several follow-up protocols including
short-term follow-up after 3 months, intermediate-
General principles term follow-up after 6-12 months, and long-term
• A high number of nevi, particularly when clinically monitoring over years.
atypical, is the strongest risk factor for the • However, for patient compliance, the first follow-
development of de novo melanoma. Early evolving up visit after baseline documentation should be
melanomas are often not recognizable, as they are scheduled after 3 months, and then, depending on
small, uniformly colored and regularly outlined, the situation, every 6-12 months.
and consequently, mistaken for an otherwise • With the exception of nevi in childhood or young
common nevus. Because most melanomas arise adolescence, any lesion in adults showing even
de novo, the main challenge in the management of subtle changes after 3 months’ follow-up, or with
patients with multiple, atypical nevi represents the asymmetric enlargement accompanied by
identification of initial melanomas hiding among a significant structural changes after 6-12 months,
sea of nevi. should be excised.
• Total-body photography and periodic digital • Equivocal nodular or blue lesions must never be
dermoscopic monitoring improve the early followed up but should be immediately excised
recognition of melanoma, as it adds information at the time of visit. This is because, in the case
about the evolution over time, which in turn of melanoma, the tumor will be already invasive and
assists in diagnosis. The premise behind digital even a 3 months’ delay may worsen the prognosis.
follow-up is that stable lesions are biologically • Growing nevi in childhood or young adolescence are
indolent and thus of no concern, whereas some of characterized by a peripheral rim of globules or by
the new and/or changing lesions may prove to be peripheral streaks in the case of flat evolving
melanomas. These initial melanomas, if followed pigmented Spitz/Reed nevi. When performing digital
over months to years, will eventually manifest follow-up, it should be kept in mind that these nevi
enough atypical clinical criteria allowing for their tend to enlarge symmetrically, the growth being at
discovery. times accompanied by structural changes.
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Figure 309 Evolving nevus
Evolving nevi are very common around puberty and early adolescence and reveal a peripheral rim of
globules (left). During follow-up, these nevi will symmetrically enlarge until the final disappearance of
globules indicates stabilization of growth. Right: Dermoscopic digital image of the nevus seen on the left
at baseline (upper right). Follow-up after 6 months shows a symmetric enlargement without significant
structural changes (middle right). Follow-up of 12 months after baseline documentation shows a
significant symmetric increase in size but no structural changes (lower right).
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Figure 310 Reed or pigmented Spitz nevus

Reed nevi and pigmented Spitz nevi are rapidly growing nevi that may show a significant enlargement
even after short-term follow-up of 6 months. Left upper image: This high-quality baseline image of a
pigmented Spitz nevus is located on the finger of a 6-year-old boy. Dermoscopically, it reveals a
symmetric distribution of peripheral streaks. Top right: Follow-up after 6 months shows a significant
enlargement of the nevus. Digital follow-up of pigmented Spitz nevi could be considered optional in
children, while excision is recommended after puberty. Bottom left and right: Corresponding digital
dermoscopic images of the same nevus as shown in the top left and right, respectively. It becomes
obvious that although digital systems are sufficient to allow the observation of changes by side-by-side
comparison of baseline and follow-up images, they do not provide sufficient quality to be used as
diagnostic screening tools—for the latter, a simple handheld dermoscope is sufficient.
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Figure 311 Melanoma in situ
This small melanoma is located on the leg of a 45-year-old woman with multiple nevi (top left). The top
right image shows the melanoma at baseline, while the bottom right image shows the follow-up of the
lesion after 4 months. Changes such as asymmetric enlargement and appearance of new structures such
as an atypical network and black dots can be seen. Lesions that change after such short periods should
always be excised. The bottom left image shows the bottom right digital dermoscopic image at high
resolution.
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Lesions with regression white veil. These can now be diagnosed as blue-
white structures.
General principles • Blue-white structures are high-risk criteria seen in
• A bone-white color often represents scarring seen in melanomas or Spitz nevi.
regression. • Superficial spreading melanomas often have areas
• Do not confuse hypopigmentation with regression. of regression.
• A blue-white veil is a bluish groundglass-appearing • If even a hint of a blue-white structure is identified,
area that can also be seen with regression. it is better to err on the side of caution and make a
• At times it is not possible to tell whether one is histopathologic diagnosis.
dealing with a white area of regression or a blue-
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Figure 312 Melanoma

The white color in the left part of this lesion (asterisk) is slightly whiter than the surrounding skin; also
adjacent to it there are numerous blue structures corresponding to melanophages in the papillary dermis.
Therefore by definition we interpret this as a regressive melanocytic proliferation. The significant
asymmetry of color and structure points toward the diagnosis of a melanoma and the beginner has to
raise the red flag here. Histopathology revealed a superficial melanoma with focal regression.

In contrast to Figure 312, the light color (asterisk) is not light enough to be considered a regression area.
However, there is clear-cut asymmetry in color and structure and we raised the red flag and excised the
lesion. Histopathology, however, showed only a Clark (dysplastic) nevus and not a superficial melanoma.
This happens so often and the experienced dermoscopist knows very well that a linear correlation
between dermoscopic and histopathologic dysplasia/atypia does not exist.
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Figure 314 Melanoma

Asymmetry of color and structure—beware. There is a clearly evident white structure in the left part of this
lesion (asterisks) corresponding to pronounced fibrosis in the papillary dermis histopathologically. In
addition to the prominent asymmetry, there are remnants of an atypical pigment network (circle) visible at
11 o’clock. No doubt we raise the red flag and excise this regressive melanoma.

Is this a blue-whitish veil (circle) or a regression area characterized by white and blue areas representing
fibrosis and melanosis? The asymmetry of this lesion is mostly due to this blue-white structure. A second
pathologic opinion was requested when this was first diagnosed as a benign Clark (dysplastic) nevus.
Always try to make a good dermoscopic-pathologic correlation. If there is divergence, get a second
pathologic opinion. And remember, whatever the histopathologic diagnosis of this lesion will tell you,
excision was the correct choice.
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* *
Figure 316 Melanoma

This slightly pinkish melanoma has a prominent white structure (asterisks). This whitish area causes
asymmetry of color and structure and despite the lack of any other melanoma-specific dermoscopic
criteria, this lesion should be considered to be a melanoma until proven otherwise. Consequently, we
raised the red flag.
*
*
*

This only slightly asymmetric lesion is very difficult to diagnose. Although there are zones with white
structures (asterisks) and also a few granular blue areas (also called peppering), the overall impression of
this lesion is a benign regressive melanocytic proliferation, as no other melanoma-specific dermoscopic
criteria can be found. Still we raised the yellow flag and performed a diagnostic excision. However,
we did not challenge the diagnosis of a benign Clark (dysplastic) nevus.
179
Flat lesions on the face • Do not expect to see “classic” site-specific criteria. If
there is a possible site-specific criterion, then
General principles consider it to be one.
• The clinical appearance and initial “gut” • Many high-risk lesions on the head and neck area
impressions should not be ignored when are relatively featureless. Look for subtle high-risk
evaluating flat brown lesions on the head and neck. clues such as different shades of color
• Do not confuse the follicular ostia of a melanocytic asymmetrically located in the lesion.
lesion with the milia-like cysts of a seborrheic
keratosis. Many times you will not be able to tell
the difference.
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Figure 318 Lentigo maligna on the nose
Are any site-specific, melanoma-specific criteria visible here? There are few asymmetrically pigmented
follicular openings (arrows), no annular-granular structures, and no clear-cut rhomboidal structures. There
is a very subtle hint of a gray pseudonetwork. The asymmetry of different shades of brown and gray color
is another clue for this early type of lentigo maligna. We raised only the orange flag here, but performed a
shave biopsy, which confirmed the diagnosis.

Is this a melanocytic or a nonmelanocytic lesion? There are no site-specific, melanoma-specific criteria
present. However, there is a slight asymmetry of different shades of brown and gray. The concavity of the
border’s “moth-eaten” appearance (arrows) and the so-called jelly sign (brownish pigmentation appearing
as a smear at the periphery of the lesion) is a clue to the correct diagnosis of solar lentigo. Because of the
asymmetry in shape and color, the orange flag was raised and a diagnostic shave biopsy was performed.
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*
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Figure 320 Flat seborrheic keratosis

This image shows asymmetry of color and structure with two site-specific, melanoma-specific criteria—
asymmetrically pigmented follicular openings (arrows) and annular-granular structures (asterisks). In this
case, these were false-positive high-risk criteria. A second opinion on the pathology should be considered
with this benign lesion.

Although this shows asymmetry of color and structure and a suggestion of rhomboidal structures (circle),
the definite, stereotypical milia-like cysts (arrows) allow the diagnosis of a seborrheic keratosis.
Remember, however, milia-like cysts can also be seen in melanocytic lesions. If in doubt, cut or
shave it out.
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Figure 322 Lichen planus-like keratosis
It is necessary to develop a differential diagnosis for all dermoscopic criteria, and such knowledge is
needed for difficult-to-diagnose lesions like this. There are multiple bluish dots and globules (circle). They
are annular-granular structures made up of melanophages. Melanophages can be seen in melanocytic,
nonmelanocytic, benign, or malignant lesions. The extensiveness of the melanophages points to a benign
lesion.
Figure 323 Lentigo maligna

This solitary flat pigmented lesion on the upper cheek shows numerous so-called rhomboidal structures
particularly in its upper half. No doubt that the dermoscopically prominent asymmetry in color and
structure will lead even the novice to the diagnosis of lentigo maligna. Raise the red flag!
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Nodular lesions on the face • A macular component to a nodular lesion should raise
the index of suspicion that the lesion could be high risk.
General principles • A soft compressible nodule that can be easily moved
• The differential diagnosis of pigmented and from side to side favors low-risk pathology. Do not
nonpigmented nodules on the face includes hesitate to palpate or squash lesions down and move
melanocytic, nonmelanocytic, benign, and them from side with the instrumentation used.
malignant lesions. Quite often, the clinical • The main differential diagnosis for nodular lesions
appearance is nonspecific, and dermoscopy will on the face are nevi and basal cell carcinomas.
help in making a clinical diagnosis. Nodular melanoma is rarely found in this area. Do
• Nodules often have ridges and fissures. Do not not forget squamous cell carcinomas including
confuse pigmentation in the fissures with an keratoacanthomas.
atypical pigment network.
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A pigment network, dots and globules, and streaks are not seen, so consider this to be a nonmelanocytic
lesion. Some nevi can have this dermoscopic picture but are usually soft and can be easily moved from
side to side. Clinically this looks like a basal cell carcinoma. There are some larger vessels, but they are
not the stereotypical arborizing ones. Rarely amelanotic melanoma looks like this.
Figure 325 Dermal nevus

Pink color—beware. Soft, movable lesion—relax. Although there are definite arborizing vessels (arrow),
the history and soft nodule point to benign pathology. If in doubt, cut it out. N.B. hairs are virtually never
seen in a basal cell carcinoma.
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*
* *

What criteria are seen here? A milia-like cyst (arrow) or a scale? There are also arborizing vessels
(asterisks) and an asymmetrical border of pigmentation. These are confusing criteria, so it is best to find
out what the lesion is more specifically.

This lesion has globules (circle) and arborizing vessels (arrows)—criteria for a melanocytic lesion and a
basal cell carcinoma. What is the history? If the patient is a young adult, a nevus is more likely, but if this is
on an adult, seriously consider basal cell carcinoma. Hairs are never seen in a basal cell carcinoma.
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Figure 328 Keratoacanthoma
This nodular lesion clearly reveals a keratotic area (circle) and numerous dark-red to black streaks
(arrows) simply representing hemorrhage. The clearly visible vessels display neither the characteristic
arborizing architecture of nodular basal cell carcinomas nor the dotted or irregular linear vessels found in
melanomas. The diffuse whitish coloration around the vessels favors a keratinocytic proliferation, and
because of the overall asymmetry, we recommend raising the red flag here. The histopathologic diagnosis
was keratoacanthoma, a distinct type of keratinocytic lesion that is interpreted nowadays by most (but not
all!) pathologists as a specific variant of squamous cell carcinoma.

This lesion looks worrisome despite its relative symmetry of color and structure. There is a prominent
central keratotic plug, and both a whitish and pinkish coloration can be seen. The vessels are not
pathognomonic and together with the keratotic plug rule out a nodular melanoma and a nodular basal cell
carcinoma with a high level of confidence. Raise the red flag and excise this lesion under the working
diagnosis of keratoacanthoma or squamous cell carcinoma. Most pathologists will call the lesion
squamous cell carcinoma, keratoacanthoma type. 187
Acral lesions • Lattice-like and fibrillar patterns ¼ benign nevi.
• Purple color and variations of red color ¼ blood.
General principles • Blood can be found in nail apparatus and
• Asymmetry of color and structure—rule out acral lentiginous melanomas; therefore, if blood is
melanoma seen, always search for melanoma-specific criteria.
• Parallel ridge pattern ¼ melanoma.
• Parallel furrow pattern ¼ nevus.
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Figure 330 Nevus
Parallel ridge? Parallel furrow? The linear darker brown color is pigmentation in the furrows (black arrows).
White dots, the “string of pearls” (white arrows), are always in the ridges. There is also a blue-white
structure in the center of the lesion. Err on the side of caution and do a biopsy, and the dermoscopist will
feel more confident the next time he or she sees a nevus that looks like this.
Figure 331 Melanoma

This lesion shows the parallel ridge pattern (solid arrows). There is also asymmetry of color and structure,
atypical dots and globules (open arrows), and a blue-white structure (asterisk). This is a melanoma until
proven otherwise.
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Figure 332 Melanoma

Parallel ridge? Parallel furrow? The string-of-pearls white dots of the sweat duct pores cannot be seen
clearly, but this is the high-risk parallel ridge (arrows) pattern. If the dermoscopist is not sure what to do,
the irregular dots and globules (circle) are worrisome enough by themselves to warrant a biopsy.
Figure 333 Melanoma

Parallel ridge? Parallel furrow? Does this look like the parallel furrow pattern of a benign nevus? Because
of the scaly surface, the exact location of the parallel pigmented bands is difficult to determine. Closer
scrutiny, however, reveals that the parallel pigmented bands (arrows) are separated only by thin
whitish lines. The brownish color does not support at all hemorrhage or a vascular lesion. Despite the
overall very subtle appearance of this lesion, we have to raise the red flag. Histopathology confirmed a
melanoma in situ.
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Figure 334 Subcorneal hemorrhage
Is the color here black or purple? It is purplish and amorphous (structureless); therefore it is blood. Take a
needle and poke some out. Needling is a simple test to confirm that one is dealing with blood. Another
clue that this is blood is the purplish dots adjacent to the lesion.
Figure 335 Subcorneal hemorrhage

This is the color of blood, but with a distinct pattern. Parallel ridge? Parallel furrow? Check the
surrounding skin. Ridges are thicker than furrows. The blood is in both. The ridges are the darker lines. If
unconvinced, needle out some of the dried blood. Take into consideration that usually your patients will
not recall a trauma. Otherwise they would not seek your advice.
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Pigmented lesions of the nails pigmented bands, irregular blotches, irregular dots
and globules, and Hutchinson’s sign.
General principles • Blood can be found in NAM, so look for high-risk
• Dermoscopy makes the nail apparatus clearer. criteria if you find blood in the nail.
• Nail-apparatus melanoma (NAM) accounts for • The chance of finding high-risk pathology in the
1-2% of melanomas in the lighter skinned pediatric population is low; therefore, a worrisome
population and 15-20% of melanomas in darker history might be more important than a high-risk
skinned people. dermoscopic appearance.
• Amelanotic NAM exists, so pink color—beware.
• High-risk dermoscopic criteria suggestive of NAM
include asymmetry of color and structure, irregular
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Figure 336 Hemorrhage
This is a stereotypical example of a subungual hemorrhage characterized by a dark-red to black diffuse
blotch revealing the color of dried blood. In addition, there is a tiny blotch at the distal end of the nail plate.
Even if this patient can not recall some form of trauma to the nail, we confidently raise the green flag here.

This image shows another variation of the morphology seen with blood. The purple color is important. It is
well demarcated and relatively structureless. Hemorrhage can present as diffuse blotches, dots and
globules, and streaks. Also here we raise the green flag and can reassure the patient that this is not a
subungual melanoma.
193

The dark dried blood in this nail is well demarcated, featureless, and in the middle of the nail plate. It is
growing out. Follow patients carefully to avoid missing NAM masquerading as blood.
*
* *

There are many faces of nail-apparatus hemorrhage. Always look for high-risk criteria before diagnosing
pure hemorrhage. Here the reddish blotches of blood are in a jelly-like area of decomposing blood
(asterisks).
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Figure 340 Nevus
The history of this lesion, age, and ethnicity of the patient should be considered together with the
dermoscopic picture before deciding on the management of nail-apparatus pigmentation. In this case,
there is uniform color and uniform linearity of the bands—a benign feature in most cases. As a rule, we
recommend annual follow-up in persons with linear nail pigmentation.
Figure 341 Melanoma

In a young patient, this irregularly pigmented band has not been correlated with high-risk pathology. In an
adult, a solitary pigmented band with different shades of brown and different widths of the lines is high
risk and requires a histopathologic diagnosis. This is a stereotypical example of a high-risk nail-apparatus
dermoscopic picture. It is necessary to focus attention to find these significant changes. Note the
pigmentation on the skin—a positive Hutchinson’s sign.
195
Mucosal lesions • Brown-black color—melanocytic.
• If a pigmented skin lesion looks worrisome
General principles clinically, shows asymmetry of color and structure,
• Most pigmented lesions on mucosal surfaces are and has melanoma-specific criteria, it does not
low risk. matter where on the body it is located. These
• Determine whether the lesion is black, brown, blue, criteria are high risk and warrant a histopathologic
or red. diagnosis.
• Red-blue color—nonmelanocytic.
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Figure 342 Labial lentigo
This pigmented lesion on the lower lip is characterized by curvilinear pigmented lines in the upper half and
a reticular pattern in the lower half. There are two shades of brown. Carefully we raised the orange flag
and recommended a diagnostic shave biopsy or a short-term follow-up to reassure no major changes.
Histopathology then confirmed the diagnosis of a benign labial lentigo.
Figure 343 Venous lake

This is a stereotypical venous lake with a homogeneous dark-blue color. The patient can be reassured
that this is benign once it has been squashed down easily and the color disappears.
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Figure 344 Labial lentigo

This pigmented lesion was present on the inferior part of the introitus vaginae of a 46-year-old patient.
She could not recall how long the lesion was there and despite the small size this lesion displays a rather
worrisome dermoscopic picture with multiple shades of bluish coloration. We raised here the red flag and
excised the lesion. Histopathologically, the diagnosis of labial lentigo without an increased number of
melanocytes was made.
Figure 345 Labial lentigines

This 68-year-old woman presented with several, poorly circumscribed brownish-black macules and
patches around the introitus vaginae and was concerned about a tendency of growth. Dermoscopically, a
prominent asymmetry in shape and color is observed and also a grayish hue becomes evident. No doubt
that the beginner raises the red flag here; however, we recommend punch biopsies from two or three
patches to obtain a presurgical diagnosis. The histopathologic examination revealed features of a benign
labial lentiginosis with a slight increase of melanocytes. We suggest regular follow-up of these patients in
a dedicated Pigmented Skin Lesion Clinic.
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Figure 346 Genital nevus
This 15-year-old girl presented with a rather large, darkly pigmented lesion on her vulva with a stable
clinical course. Dermoscopy exhibits a homogeneous brown-gray coloration with few intermingled
whitish-yellowish dots. The latter can be observed also in the surrounding normal skin and represent
sebaceous glands. Because of the bland history and the prominent homogeneous pattern, we
recommend annual follow-up.
Figure 347 Melanoma

This is a melanoma of the vulva. No other diagnosis should come to mind on seeing this clinical and
dermoscopic picture. This large asymmetrical lesion shows blue-white structures and irregular dots and
globules.
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Differential diagnostic value of blood Melanocytic lesions
vessels • Dermal nevi—comma-shaped vessels.
General principles • Clark (dysplastic) nevi—comma-shaped and dotted
vessels.
• Blood vessels can be seen in melanocytic, • Melanoma—dots and irregular linear vessels or
nonmelanocytic, benign, and malignant lesions. milky-red areas.
• Vessels can be seen with other criteria, or vessels
may be the only criterion found in a lesion. Nonmelanocytic lesions
• Some vessels are associated with high-risk
• Basal cell carcinoma—thick branching (arborizing)
pathology and others with low-risk pathology.
vessels.
• Pink lesions with vessels may be melanocytic,
• Seborrheic keratosis—hairpin vessels.
nonmelanocytic, benign, or malignant. The shape
• Bowen’s disease—small foci of dotted vessels that
of the vessels may provide a clue to the correct
look like glomeruli in the kidney.
diagnosis.
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The correct diagnosis for this dermal nevus without pigmentation is suggested by the shape of the
vessels. They are comma shaped (arrows). A few comedo-like openings, milia-like cysts, and a hair follicle
are also present. Do not confuse these vessels with the larger branching vessels seen in a basal cell
carcinoma.
*
*
*

This lesion shows very subtle remnants of a pigment network and a few dots and globules (circle);
therefore, it is a melanocytic lesion. There is a combination of comma-shaped (arrows) and dotted
(asterisks) vessels.
201

This pinkish lesion lacks pigmentation. Remember pink color—beware, so it could be high risk. It is a
stereotypical example of a nonpigmented Spitz nevus with numerous dotted vessels evenly distributed
throughout the lesion. The color in this lesion is strikingly pink, also known as milky-red and resembles the
color of a strawberry milkshake. Milky-red color and dotted vessels are a high-risk pattern that can be
seen in nonpigmented Spitz nevi and melanoma. It is not always possible to differentiate Spitz nevi from
melanoma, nor does it matter. A biopsy is indicated (red flag!) to rule out an amelanotic melanoma.
Figure 351 Melanoma

This lesion displays striking asymmetry of brown-gray-blue and white color and a paracentral zone (circle)
characterized by densely packed irregular linear vessels and variations on the theme of hairpin vessels,
underpinning the diagnosis of melanoma. The overall irregularity and vascular pattern visible here is not
compatible with the diagnosis of a seborrheic keratosis or a basal cell carcinoma.
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Figure 352 Melanoma
This is a rather dramatic “featureless” amelanotic melanoma with a delicate gray-brownish peripheral ring.
This ring as well as the paracentral scaling has no diagnostic significance at all. Overall the lesion is raised
and shows a milky-red color with fine irregular linear vessels. Milky-red color—beware!
Figure 353 Melanoma

A keratotic area (circle) does not make this a seborrheic keratosis nor does it rule out a melanoma. Dotted
(arrows) and irregular linear vessels (asterisks) are usually not seen within a seborrheic keratosis.
Dotted vessels and linear-irregular vessels are the most common combination of vascular pattern in
melanoma, and a red flag must be always raised.
203

This is a commonly seen basal cell carcinoma without pigment. The blood vessels, which are thick and
branching (arrows), point to the correct diagnosis. The vessels are superficial and are therefore in focus. If
the vessels are deeper in the lesion, they would be blurred and out of focus. If so, think amelanotic
melanoma.

If there could be one, then this is a classic keratoacanthoma with hairpin-shaped vessels (arrows) and a
white background. The white color is not always scarring seen with regression but in this case represents
hyperkeratosis seen in keratinizing tumors. White color can be seen in melanocytic, nonmelanocytic,
benign, and malignant lesions. The central crust plus the history and clinical appearance all help in
determining the management of this lesion.
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*
*

This is an irritated, smoothly polished seborrheic keratosis. Note that only few comedo-like openings
(arrows) are visible. The gray color (asterisks) represents pigmentary incontinence probably secondary to
inflammation and gives this lesion a worrisome look. Numerous hairpin vessels (not exclusively within
the circle) can be identified and are suggestive for a seborrheic keratosis. Still, we raised the orange flag
and performed a diagnostic shave biopsy.

This is another example of a rather unusual nonpigmented seborrheic keratosis characterized by
numerous dotted, linear irregular, and some hairpin-shaped vessels. Such a polymorphic vascular pattern
may well be observed also in an amelanotic melanoma. So we raised the orange flag and were happy
to hear that histopathologically this lesion only represented an acanthotic type of seborrheic keratosis as
we originally suspected.
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Figure 358 Bowen’s disease

Pigmented Bowen’s disease is a difficult clinical and dermoscopic diagnosis to make. It is usually a
surprise to obtain this pathology report when in most cases a potentially high-risk melanocytic lesion has
been suspected. Here we see well-circumscribed round areas of red vessels looking like a renal
glomerulus (circle) and tiny brown dots packed together tightly (arrows).
Figure 359 Clear cell acanthoma

Pink lesions with this pattern of dotted vessels as the only criteria are totally nonspecific at the first blush.
The differential diagnosis includes melanocytic, nonmelanocytic, benign, and malignant lesions. If there is
only one lesion, excise it. The presence of several lesions points to low-risk pathology. Biopsy one to
make a dermoscopic-pathologic correlation and you will be surprised. This pattern of dotted vessels
depicted here is actually rather typical for the diagnosis of clear cell acanthoma.
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Amelanotic and partially pigmented • Dotted and linear irregular vessels are suggestive of

melanoma melanomas or, in more general terms, two or more
different morphologic types of vessels should raise
General principles your suspicion for a melanoma.
• Amelanotic or hypomelanotic melanomas often • Many amelanotic and hypomelanotic melanomas
present clinically unequivocal. display atypical, polymorphic vessels.
• The history of growth or change is of uppermost • The arrangement of vessels in amelanotic or
importance. hypomelanotic melanomas is asymmetric and
• Use the EGF rule: Elevated Firm Growing lesions irregular.
are suspicious. • Frequently you find remnants of pigmentation in
• Study carefully the vessels in pink lesions. amelanotic melanomas (of course, then the term
• Vessels are in many cases the only clue for the “hypomelanotic melanoma” is more appropriate).
correct diagnosis. • Search for residual pigment network structures,
• The dermoscopic examination of amelanotic or brown or blue blotches and/or brown, gray, or
hypomelanotic lesions should follow a stepwise black dots/globules.
algorithm assessing the morphology of the vascular • Histopathology is obligatory in lesions displaying
pattern, the architectural arrangement of vessels, dotted, linear irregular, or polymorphic vessels or
and the presence of additional dermoscopic exhibiting a milky-red color.
criteria.
207
Figure 360 Melanoma

By default, this is a melanocytic lesion because it lacks criteria for any other lesion such as a basal cell
carcinoma or seborrheic keratosis. The colors are smudged or out of focus. There is also asymmetry of
color and structure. White color—beware.
Figure 361 Melanoma

Pink color—beware. The small reddish dots (arrows) could be one of the vascular patterns seen in
melanoma. Is the grayish blotch (circle) created by macrophages in the papillary dermis or pigmented
melanoma cells? (Figure courtesy of MA Pizzichetta, Aviano, Italy.)
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Figure 362 Melanoma
This is a melanocytic lesion because there is an absence of obvious criteria to diagnose other lesions.
White color—beware. Do not mistake it for the central white patch of a dermatofibroma. There is also pink
color and the small dotted (circle) melanoma-specific vascular pattern. All these subtle criteria spell
melanoma until proven otherwise.
Figure 363 Melanoma

This is a subtle and difficult case. Could this be a collision lesion? Pink color—beware. Is this an ugly
duckling lesion? Look to see if the patient has other similar lesions. It is less worrisome if so. The small red
dots of the melanoma-specific vascular pattern (circle) can be seen. Is the color gray or brown, and does
it matter? Gray could represent the melanophages seen in regressing melanomas. The colors in this
lesion plus the dotted vascular pattern are sufficient clues to warrant a histopathologic diagnosis.
(Figure courtesy of MA Pizzichetta, Aviano, Italy.)
209
Figure 364 Melanoma

This hypopigmented lesion is characterized by subtle asymmetry in color and structure. Note the relatively
pronounced pinkish coloration clearly visible with dermoscopy. This lesion is particularly worrisome when
no similar lesions are found in the same patient. This was the case here and therefore we raise the red
flag. This lesion was excised and diagnosed histopathologically as superficial melanoma.
Figure 365 Melanoma

The only clue here that this might be a high-risk lesion is the presence of few gray blotches (circle),
which could be melanophages in a regressing melanoma. The differential diagnosis here represents
an unusual combined nevus; however, do not be too brave with inventing benign diagnoses for equivocal
pigmented lesions. Raise the red flag and act accordingly.
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Dermoscopy tests Blanching test

General principles Clark nevi, particularly in subjects with fair skin types
or when located on seborrheic areas of the trunk, may
Several features such as scales, crusts, or inflammation at times reveal erythema, which does not allow the
may cause uncertainty in the dermoscopic diagnosis of proper recognition of the pigmented structures.
skin lesions. On these occasions, simple dermoscopic In such a case, the blanching test by applying pressure
tests may aid to obtain the correct diagnosis. on the nevus with the dermoscope may be helpful.
Tape test This will result in the disappearance of the erythema,
which in turn allows a better visualization of the
A nevus often raising concern is the so-called black or pigmented structures.
hypermelanotic nevus. The reason is its dark color and
a more or less centrally located black blotch covering The Wobble sign
most of the nevus. The black blotch correlates During the dermoscopic examination of a nodular
histopathologically to pigmented parakeratosis of an pigmented skin lesion, the dermoscope can be
otherwise conventional junctional nevus. Yet, this maintained fixed at the surface of the skin. If the
pigmented scale (or black blotch) can be easily device is slightly moved horizontally, parallel to the
removed by a tape or plaster, which allows the surface, a dynamic approach is added. The lesion
recognition of the underlying otherwise regular sticks to the dermoscope and follows its movement.
network. The tape test therefore facilitates the In the cases of papillomatous dermal nevi, the lesion
nevus diagnosis. follows the movement of the dermoscope, leaving
Scrape test back the surrounding skin. The static pattern of the
nevus itself is dissociated, and deeper structures having
The differential diagnosis of acral lesions showing a a fleshy consistency seem to move under the
parallel ridge pattern is between acral melanoma and superficial component. In contrast, melanoma tends
subcorneal hemorrhage. In doubtful cases, the scrape to be firm and fixed to the skin and is therefore not
test can be performed. Simply scrape the cornified easily moveable.
layer with a scalpel, and if this scraping results in the
removal of the pigment, a diagnosis of subcorneal
hemorrhage can be made with confidence.
211
Figure 366 Tape test

Black nevus with a centrally located dark scale covering large parts on the nevus.
Figure 367 Tape test

The same nevus as shown in Figure 366 after removal of the dark scale with tape (inset: the dark scale
can be seen fixed on the tape). The regular network is now much more evident.
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Figure 368 Scrape test
Subcorneal hemorrhage revealing a parallel ridge pattern. The sharp demarcation and red color already
point toward the correct diagnosis.
Figure 369 Scrape test

The same hemorrhage as seen in Figure 368 just a few minutes later, after nearly complete removal of the
blood with a scalpel.
213
Figure 370 Blanching test

Dermoscopy of this pinkish Clark nevus reveals a background erythema, dotted vessels, and some
shades of light-brown color.
Figure 371 Blanching test

The same nevus as seen in Figure 370 under pressure. The erythema and dotted vessels have mostly
disappeared and a regular light-brown network surrounding a central structureless area becomes visible.
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Figure 372 Wobble sign
Dermoscopic static view of a slightly papillomatous dermal nevus showing shades of brown and gray
color and vascular patterns.
Figure 373 Wobble sign

Movement of the dermoscope allows the visualization of the right lateral base of the papillomatous dermal
nevus.
215
Further reading
Akasu R, Sugiyama H, Araki M, et al: Dermatoscopic Argenziano G, Scalvenzi M, Staibano S, et al:

and videomicroscopic features of melanocytic Dermatoscopic pitfalls in differentiating pigmented
plantar nevi. Am J Dermatopathol 18:10–18, 1996. Spitz naevi from cutaneous melanomas.
Altamura D, Avramidis M, Menzies SW: Assessment of Br J Dermatol 141:788–793, 1999.
the optimal interval for and sensitivity of short- Argenziano G, Soyer HP, Chimenti S, et al:
term sequential digital dermoscopy monitoring for Dermoscopy of pigmented skin lesions: results of a
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ERRNVPHGLFRVRUJ
Index
Note: Page numbers followed by b Age of patient, taking account of Asymmetry (color or structure)
indicate boxes, f indicate figures and (Continued) (Continued)
t indicate tables. nail-apparatus pigmentation, 195f seborrheic keratosis, 6f, 24f, 99f,
Spitz nevus on leg of middle-aged 120f, 123f, 124f, 126f, 182f
A woman, 72f solar lentigo, 80f
Acanthotic epidermis, 78 Algorithms (analysis criteria), 1–2, 33 Spitz nevus see Spitz nevus
Acral lesions Amelanotic melanoma see under spitzoid lesion, 90f
asymmetry of color/structure, 105f, Melanoma Atypical pigment network
189f Anamnestic data, melanoma diagnosis, Clark (dysplastic) nevus see Clark
benign type, 102f, 104f 64f (dysplastic) nevus
blue-white structures, 189f Angiokeratoma melanoma see Melanoma
dermoscopic principles, 100–106, multicomponent global pattern, nevus (nevi) see under Nevus (nevi)
188–191 78 Spitz nevus, 13f
dots and globules, 102f, 103f, red-blue lacunas, 107
189f Annular-granular structures B
fibrillar pattern, 104f, 105f actinic keratosis, pigmented, 99f Back, nevi on, 143f
follow-up, 105f definition, 93 Basal cell carcinoma
lattice-like pattern, 101f, 103f lentigo maligna, 95f arborizing vessels, 10f, 53f, 56f, 107,
management approach, 103f lentigo maligna melanoma, 95f 108f, 109f, 110f, 111f, 112f,
melanoma and, 101f, 106f, lichen planus-like keratosis, 183f 113f, 116f, 186f
189f melanoma see Melanoma absent, 117f
multiple colors, 103f seborrheic keratosis, 182f atypical, 109f
nevus, 101f, 189f Antibiotic treatment, Meyerson nevus, microarborizing, 110f, 116f
parallel-furrow pattern, 101f, 102f 165f present outside lesion, 113f
parallel patterns, types, 100–106, Arborizing vessels, 107 asymmetry, 10f, 11f, 15f, 19f, 31f,
100b basal cell carcinoma see under Basal 32f, 186f
parallel-ridge pattern, 106f, 189f cell carcinoma blood vessel appearance, 53f, 94f,
furrow pattern vs, 102f dermal nevus, 56f, 186f 112f, 153f, 204f
plantar surfaces, pressure areas, microarborizing, in basal cell small linear, 115f
105f carcinoma, 110f, 116f blue-gray blotches, 107, 108f, 109f,
in situ melanoma, differential Asymmetrically pigmented follicles, 110f, 111f, 112f, 113f, 114f,
diagnosis, 106f, 190f 94f, 96f 115f, 116f, 117f
‘string of pearls,’ 101f, 103f, 106f, description, 93 absent, 117f
189f, 190f seborrheic keratosis, 182f blue-white structures, 10f, 11f, 15f,
subcorneal hemorrhage, 191f Asymmetry (color or structure) 19f, 31f, 32f, 108f, 115f, 154f
Acrosyringia, 101f, 103f acral melanocytic lesions, 105f crusts surrounding mini-ulcerations,
Actinic keratosis, 97f, 99f actinic keratosis, 97f 113f
Actinic lentigo, seborrheic keratosis basal cell carcinoma see under Basal differential diagnosis
evolving from, 99f cell carcinoma amelanotic melanoma vs, 185f,
Adolescents Clark (dysplastic) nevus, 12f, 21f 204f
evolving nevi, 173f combined nevus, 77f blue nevus vs, 109f, 112f
follow-up of lesions, 172 congenital nevus, 63f dermal nevus vs, 56f
globular nevus seen in, 43f inkspot lentigo, 150f dermatofibroma vs, 110f
melanoma in, 142f keratoacanthoma, 187f hemangioma vs, 110f
Sutton nevus, 165f labial lentigines, 198f keratoacanthoma vs, 187f
see also Pediatric patients lentigo maligna, 183f melanoma vs, 11f, 78, 88f, 94f,
Age of patient, taking account of, 12f melanoma see Melanoma 108f, 110f, 112f, 114f, 116f,
melanoma nevus (nevi), 4f, 6f, 8f, 17f, 20f, 26f, 117f, 153f, 154f, 202f, 204f
on 45-year old women, multiple 27f, 28f, 29f, 31f nevus vs, 25f, 53f
nevi, 175f slight asymmetry, 12f, 14f, 21f, seborrheic keratosis vs, 110f, 124f,
before or following puberty, 140f 25f, 26f, 41f 127f
223
Basal cell carcinoma (Continued) Blood vessels (Continued) Blue nevus (Continued)
globules, 153f dermal nevus, 201f history, 155f
gray zone, 115f dermatofibroma, 137f homogeneous color, 27f, 67f, 155f
hairs never seen in, 185f, 186f diagnostic value of homogeneous pattern, 33, 64f, 67f
irregular dots and globules, 154f general dermoscopic principles, 200 hypomelanotic melanoma vs, 66f
leaf-like area, 114f, 117f melanocytic lesions, 200 milia-like cysts, 155f
multicomponent global pattern, 78 non-melanocytic lesions, 200–206 nodular melanoma vs, 153f
nodular, 10f, 31f, 32f, 113f dotted, 201f, 202f, 203f, 205f, 206f, pigment network, absent, 27f
differential diagnosis, 25f, 117f, 207, 209f, 214f stereotypical, 64f, 65f
187f hairpin-shaped, 202f, 204f, 205f symmetry of color and structure, 27f
on face, 185f, 186f, 187f keratoacanthoma, 187f, 204f whitish area in, 65f, 66f
pigment network linear irregular, 202f, 203f, 205f, 207 Blue-white structures
absent, 10f, 11f, 15f, 19f, 31f, 32f melanoma, 116f, 187f, 202f, 203f basal cell carcinoma see under Basal
heavy pigmentation, 116f, 117f amelanotic and partially cell carcinoma
pink color, 110f, 115f, 116f, 117f pigmented, 207–210, 208f, blue nevus, 66f
pressing down hard a danger for, 108f 209f, 210f bluish dots and globules confused
stereotypical, 111f renal glomerulus type appearance, with (nevi), 54f
ulceration, 110f, 111f, 112f, 113f, Bowen’s disease, 206f and central hypopigmentation, 29f
115f, 132f, 153f, 154f seborrheic keratosis, 205f Clark (dysplastic) nevus, 35f, 51f,
Biopsy Spitz nevus, 69f, 141f, 202f 178f
Clark (dysplastic) nevus, 48f thrombosed, hemangioma, 129f, congenital nevus, 58f
clear cell acanthoma, 206f 132f as high-risk, 176
labial lentigines, 198f partially thrombosed, 131f, 133f melanoma see Melanoma
labial lentigo, 197f vascular patterns, polymorphic, 205f as melanoma-specific criterion, 1
metastatic melanoma, 155f Blotches multiple anastomosing, 22f
nodular lesions, 109f acral melanocytic lesions, 104f nevus see Nevus (nevi)
seborrheic keratosis, 123f, 124f, black see Black blotch seborrheic keratosis, 24f, 121f, 123f
126f, 205f blue-gray see Blue-gray blotches Spitz nevus see Spitz nevus
solar lentigo, 181f irregular Bony white areas
Spitz nevus, 75f brownish, nevus, 53f, 59f melanoma, 78
Black blotch, melanoma, 87f Clark nevus see under Clark regression associated, 36f, 38f, 41f,
Black color/lesions (dysplastic) nevus 176
differential diagnosis, 144 inkspot lentigo, 150f Borderline lesion, characteristics, 23f
general dermoscopic principles, melanoma see under Melanoma Bowen’s disease, 200
144–147 recurrent nevi, 166f Brown pseudonetwork
lamella see Black lamella Spitz nevus, 163f actinic keratosis, 97f
melanoma, 151f regular, 78 seborrheic keratosis, 125f
nonspecific, 145f subungual hemorrhage, 193f
recurrent nevi, 166f Blue-gray blotches, 107 C
seborrheic keratosis, 124f basal cell carcinoma, 108f, 109f, Central hyperpigmentation see under
Spitz nevus, 70f, 72f, 75f 110f, 111f, 112f, 113f, 114f, Hyperpigmentation
Black dots/globules 115f, 116f, 117f Central hypopigmentation see under
melanoma, 88f absent, 117f Hypopigmentation
nevus (nevi), 6f seborrheic keratosis, 127f Central white patch
Black lamella, 36f Blue lesions dermatofibroma, 107, 135f,
Black nevus see under Nevus (nevi) basal cell carcinoma, 153f, 154f 137f
Blanching test, 211 general dermoscopic principles, melanoma vs, 209f
Clark (dysplastic) nevus, 214f 152–155 description, 107–137
dermal nevus, 215f melanoma, 154f Changes in lesions
Blood nodular, on face, 153f melanoma, 175f
nail-apparatus melanoma, 192 melanoma metastasis, 155f reticular pattern, 33
subcorneal hemorrhage, 191f nevi see Blue nevus see also Follow-up of lesions
Blood vessels Blue nevus Children see Pediatric patients
arborizing see Arborizing vessels asymmetry, 67f Chrysalis-like structures, melanoma, 5f,
basal cell carcinoma, 53f, 94f, 112f, atypical, 112f 88f
204f blue-white structures, 27f, 66f Clark (dysplastic) nevus
small linear vessels, 115f congenital, combined with, 167f adjacent to benign dermal, 39f
Bowen’s disease, 206f differential diagnosis, 64f, 65f, 66f, asymmetry, 12f, 21f
Clark (dysplastic) nevus, 201f 67f, 109f, 112f, 155f atypical pigment network, 42f, 51f,
clear cell acanthoma, 206f diffuse bluish-brown pigmentation, 151f, 157f, 158f, 170f
comma-like vessels, nevus, 53f, 55f, 67f severe atypia, 83f, 84f
201f fibrosis, 65f slight, 38f
Clark (dysplastic) nevus, 201f firm nodule with smooth surface, 66f blanching test, 211, 214f
224
Clark (dysplastic) nevus (Continued) Color, asymmetry of see Asymmetry Dermatofibroma (Continued)
Index
blotches, 170f (color or structure) milia-like cysts, 136f
blue-white structures, 35f, 51f, 78, Combined nevus pigment network, 135f, 136f, 137f
178f asymmetry, 77f pink color, 137f
benign type, 179f definition, 167f reticular depigmentation, 136f
central hyperpigmentation, 40f, 42f melanoma vs, 39f, 77f, 167f, 210f seborrheic keratosis vs, 136f
central hypopigmentation, 158f targetoid appearance, 167f stereotypical, 135f, 137f
comma-shaped vessels, 201f Comedo-like openings Dermoscopy
compound type, 38f description, 107 algorithms (analysis criteria), 1–2,
globular pattern, 48f follicular ostia vs, 95f 33
reticular-globular pattern, 39f nevus, 54f, 55f, 56f, 60f definition, 1
differential diagnosis dermal, 201f goals, 1
blue nevus vs, 65f seborrheic keratosis, 107, 118f, 119f, technique, 1
melanoma vs, 39f, 69f, 83f, 87f, 120f, 121f, 122f, 123f, 124f, 3-point checklist, 1–32
88f, 91f 125f, 126f, 147f, 205f Dermoscopy tests see Tests,
in situ melanoma vs, 21f, 38f, 42f, Comma-shaped vessels dermoscopy
61f, 157f nevus, 53f, 55f, 201f Digital dermoscopic monitoring
Spitz nevus vs, 12f, 50f, 69f, 71f, 73f Clark (dysplastic) nevus, 201f evolving nevi, 173f
superficial melanoma vs, 84f Congenital melanocytic nevus melanoma recognition, 172
diffuse homogeneous pigmentation, asymmetry, 63f, 140f Spitz nevus, 174f
50f biopsy indicated where, 139 Dots and globules
dots and globules, 35f, 48f, 157f, blue, combined with, 167f acral melanocytic lesions, 102f, 103f,
170f, 201f blue-white structures, 58f 189f
dotted vessels, 201f facial, 62f blue-gray globules, melanocytic
eccentric hyperpigmentation, 38f follow-up, 63f, 140f lesions, 116f
featureless, 170f globular-homogenous pattern, 60f Bowen’s disease, 206f
fibrosis, 178f globular pattern, 33, 58f, 59f, 63f irregular
finger-like projection, broken-up cobblestone-like shape, 140f inkspot lentigo, 150f
pigment network intermingled hairs, 61f as melanoma-specific criterion, 78
with globules, 39f multicomponent global pattern, 78 nevus, globular pattern, 48f
globular pattern, 33, 58f pediatric patients, 140f recurrent nevi, 166f
hypopigmentation, homogeneous, pigment network, 58f Spitz nevus, 75f, 76f
38f reticular-homogenous pattern, 63f see also Melanoma
junctional type, 40f reticular pattern, 58f lichen planus-like keratosis, 183f
line segmentation, 35f in situ melanoma arising in, 140f nevus (nevi) see under Nevus (nevi)
multifocal hypopigmentation, 58f, stereotypical, 58f reddish dots, 124f, 127f
170f starburst pattern, 33
multiple, 168–171 D Dysplastic nevus see Clark (dysplastic)
peppering, 179f Deep shave biopsy nevus
pigment network Clark (dysplastic) nevus, 48f
atypical, see above seborrheic keratosis, 126f E
broken-up, 39f De novo melanoma, 172 Eccrine duct openings, in Spitz nevus,
fading out, 35f, 157f Depigmentation, Sutton nevus, 165f 71f
irregular, 61f Dermal nevus Eczematous nevus, 165f
subtle remnants, 201f arborizing vessels, 56f Erythema, Clark (dysplastic) nevus,
and regression, 65f, 177f, 178f, 179f basal cell carcinoma vs, 56f 214f
reticular-globular pattern, 39f blanching test, 215f Evolving nevus (nevi), 173f
reticular-homogenous pattern, 38f blood vessels, 201f Excisional shave biopsy, seborrheic
reticular pattern, 35f, 40f, 151f, 157f, blue nevus vs, 66f keratosis, 123f, 126f
158f on face, 185f, 186f Exophytic papillary structures/ridges
variation, 42f papillomatous, 55f, 56f, 215f nevus (nevi), 56f, 60f
with severe atypia, 83f comedo-like openings, 54f, 55f, intermingled with furrows, 57f
‘ugly duckling’ lesion, 171f 56f, 60f, 107
verrucous melanoma arising within, skin-colored nodule, vs melanoma, F
90f 89f Face
Clear cell acanthoma, 206f see also Blue nevus; Clark (dysplastic) congenital melanocytic nevus on,
Clinical scenarios, common, 139–215 nevus; Nevus (nevi); Spitz nevus 62f
Cobblestone pattern Dermatofibroma diagnosis difficulties, 99f
cockade nevi, 167f basal cell carcinoma vs, 110f flat lesions on, 181f, 182f, 183f
congenital melanocytic nevus, 140f blue nevus vs, 66f general dermoscopic principles,
melanoma, 140f central white patch, 107, 135f, 136f, 180–183
nevus (nevi), 46f, 140f 137f lentigo maligna on, 181f
Cockade nevi, 167f melanoma vs, 209f melanoma-specific criteria, 93–99
225
Face (Continued) Globular-starburst pattern, Spitz nevus, Hemosiderotic targetoid nevi, 166f
nodular lesions on, 184–187 73f History of patient, taking account of,
basal cell carcinoma, 184, 185f, Globules see Dots and globules 12f, 67f, 186f
186f Gray color, seborrheic keratosis, 124f Homogeneous pattern
dermal nevus, 185f, 186f Gray pseudonetwork description, 33
differential diagnosis, 184 description, 93–99 nevus see Nevus (nevi)
general dermoscopic principles, lentigo maligna, 94f, 95f reticular-homogenous pattern
184–187 lentigo maligna melanoma, 95f see Reticular-homogenous
keratoacanthoma, 187f Gray zone lesions pattern
nodular melanoma on, 153f basal cell carcinoma, 115f Homogeneous-starburst pattern, Spitz
pseudopigment network, 122f common nature of, 139 nevus, 72f, 73f
seborrheic keratosis, 99f, 126f melanoma, 81f Honeycomb pattern see Reticular
solar lentigo on, 181f nevus (nevi), 51f pattern
Spitz tumor, atypical, 142f Hutchinson’s sign, nail-apparatus
see also under Lentigo maligna; H melanoma, 195f
Lentigo maligna melanoma Hair follicles Hypergranulosis, blue-white structures,
‘Fat fingers,’ seborrheic keratosis, 99f, holes representing, nevus, 57f, 59f 78
125f solar lentigo, 98f Hyperkeratosis, in keratinizing tumors,
Fibrillar pattern see under Acral white-appearing, actinic keratosis, 204f
melanocytic lesions 97f Hypermelanotic nevus, tape
Fibroangioma, 130f, 134f Hair/hairs test, 211
Fibrosis and basal cell carcinoma, 185f, 186f Hyperpigmentation
blue nevus, 65f congenital melanocytic nevus, 61f, blotches as, 78
blue-white structures, 78 140f see also Blotches
Clark (dysplastic) nevus, 178f Hairpin vessels central, Clark (dysplastic) nevus, 40f,
fibroangioma, 130f keratoacanthoma, 204f 42f
hemangioma, 129f, 132f, 133f, 134f melanoma, 202f eccentric
Kaposi’s sarcoma, 134f seborrheic keratosis, 205f Clark (dysplastic) nevus, 38f
melanoma, 178f Halo nevi, 165f nevus, reticular pattern, 38f
Fluid, dermoscopy technique, 1 Hand, Spitz nevus on, 147f paracentral, nevus, 41f
Follicular openings, seborrheic Head and neck lesions, ostia of perifollicular, 140f
keratosis, 85f, 126f, 139 appendages, 8f Hypopigmentation
Follicular ostia Hemangioma blue-white structures vs, 78
facial melanocytic lesions, 93–99 basal cell carcinoma vs, 110f central
seborrheic keratosis vs, 139 blue-white color, 129f, 133f Clark (dysplastic) nevus, 158f
Follow-up of lesions bluish color, 64f, 131f nevus, 29f, 41f
acral melanocytic, 105f cherry (senile), 129f, 132f homogeneous, 36f, 38f, 40f
in child/adolescent, 172 dark-red to blue-black lacunas, 130f, melanoma, 91f, 171f, 210f
labial lentigines, 198f 132f multifocal
labial lentigo, 197f differential diagnosis Clark (dysplastic) nevus, 58f,
nevus (nevi), 40f, 42f, 47f, 49f, 51f, 52f fibroangioma vs, 134f 170f
congenital nevus, 63f, 140f melanoma vs, 132f melanoma, 171f
evolving, 173f fenestrated whitish pattern, 130f, nevus, 21f
Spitz nevus, 174f 132f nevus see under Nevus (nevi)
in situ melanoma, 175f fibrosis, 129f, 132f, 133f, 134f perifollicular, 140f
Freckles, surrounding inkspot lentigo, lobular capillary, 130f vs regression, 176
148 melanoma vs, 131f seborrheic keratosis, 121f
nevus vs, 64f Hypopigmentation islands, nevus, 34f,
G purplish lacunas, 128f, 133f 58f
Genital nevus, 199f pyogenic granuloma vs, 133f
Giant congenital melanocytic nevus, red-blue lacunas, 107, 129f, 131f, I
pediatric patients, 139 133f, 134f Inflammation, Meyerson nevus, 165f
Globular-homogenous pattern reddish-black areas, 131f Injury, of pre-existing nevus, 166f
nevus (nevi), 57f red lacunas, 128f Inkspot lentigo
nevus spilus, 60f thrombosed vessels, 129f, 132f asymmetry of color/structure, 150f
Spitz nevus, 75f, 77f partially thrombosed, 131f, 133f general dermoscopic principles,
Globular pattern white color, 128f 148–151
Clark (dysplastic) nevus see Clark Hemorrhage irregular blotches, 150f
(dysplastic) nevus in middle of nail plate, 194f irregular dots and globules, 150f
cockade nevi, 167f reddish blotches of blood, 194f melanoma vs, 151f
description, 33 streaks representing, 187f pigment network, 149f, 150f
nevus see Nevus (nevi) subcorneal, 191f, 213f stereotypical, 149f
Spitz nevus see Spitz nevus subungual, 193f variation, 149f, 150f
226
In situ melanoma Lentigo maligna (Continued) Melanoma (Continued)
Index
acral, differential diagnosis, 106f, 190f on nose, 181f Clark (dysplastic) nevus vs, 88f
atypical pigment network, 38f, 157f rhomboid structures, 94f, 95f, 119f, featureless melanoma, 6f
congenital nevus, arising in, 140f 183f gray pseudonetwork, 93–99, 95f
differential diagnosis seborrheic keratosis vs, 124f, 139 lentigo maligna, 95f
black nevus vs, 52f Lentigo maligna melanoma, 95f lentigo maligna melanoma, 95f
Clark (dysplastic) nevus vs, 21f, Lichen planus-like keratosis, 183f multiple colors, 79f, 91f
38f, 42f, 61f, 157f Line segmentation, pigment network with regression, 177f, 178f
full melanoma, 21f melanoma, 5f slight, 96f
lentigo maligna vs, 94f nevus, 3f, 29f, 34f, 36f, 49f atypical pigment network, 1, 2t, 3f,
nevus vs, 30f, 36f Clark (dysplastic), 35f, 157f, 158f 5f, 7f, 9f, 15f, 16f, 18f, 19f, 21f,
Spitz nevus vs, 70f, 73f congenital, 58f 23f, 78, 79f, 81f, 85f, 86f, 89f,
early, diagnosis difficulty, 159f reticular pattern, 33, 34f 151f, 159f, 162f, 175f
follow-up, 175f Lip, labial lentigo, 197f absent, 16f
irregular dots and globules see under Lobular capillary hemangioma, 130f Clark nevus vs, 83f, 88f
Dots and globules debatable, 10f, 11f
irregular streaks, 157f M description, 78
within pre-existing nevus, 38f Macrophages, melanoma, 208f in five positive criteria, 78
reticular pattern, 157f Melanocytes, 78, 95f irregular dots/globules with, 80f
with eccentric hyperpigmentation, Melanocytic lesions blood vessels, 116f, 187f, 202f,
38f acral see Acral melanocytic lesions 203f
Instrumentation list, dermoscopy, 1 congenital nevus see Congenital blue-white color, 79f
Irregular blotches melanocytic nevus blue-white structures, 1, 2t, 3f, 4f, 5f,
nevus (nevi), 53f, 59f dermal nevus, 200 7f, 8f, 9f, 10f, 11f, 13f, 15f, 16f,
see also Melanoma follow-up, 172–175 18f, 21f, 23f, 30f, 79f, 80f, 81f,
Irregular streaks see Streaks, irregular globules, 121f 82f, 83f, 84f, 85f, 86f, 87f, 91f,
Irritation blue-gray, 116f 92f, 146f, 154f, 158f, 161f, 162f,
hemosiderotic targetoid nevi, 166f nevi see Clark (dysplastic) nevus; 163f
melanoma, 84f Nevus (nevi); Spitz nevus extensive, 91f
nevus (nevi), 56f reticular pattern, 40f, 127f five positive criteria, 78–92
seborrheic keratosis, 84f, 126f, 205f see also Melanoma irregular blotches with, 91f
Melanoma irregular dots and globules with,
J acral lesions and, 101f, 106f, 189f 85f, 88f, 91f
Jelly sign, solar lentigo, 97f, 181f in adolescents, 142f multiple anastomosing, 22f
amelanotic with peppering, 19f
K basal cell carcinoma vs, 108f, 114f, spitzoid melanoma, 90f
Kaposi’s sarcoma 116f, 117f, 204f streaks with, 5f, 89f
fibroangioma vs, 130f blood vessels, 207–210, 208f, vivid color, 85f
hemangioma vs, 134f 209f, 210f vulva, melanoma of, 199f
red lacunas, 134f dermatofibroma vs, 137f bony white areas, 36f, 38f, 41f, 78
Keratoacanthoma, 187f featureless, 203f color and structure
blood vessels, 204f fibroangioma vs, 130f asymmetry of see above
general dermoscopic principles, dark color, 22f
L 207–210 comma-shaped vessels not seen in,
Labial lentigines, 198f nail-apparatus melanoma, 192 55f
Labial lentigo, 197f partially pigmented, 207–210 de novo, 172
Lacunas pyogenic granuloma vs, 133f dermoscopy accuracy, 1, 2
borders, 129f seborrheic keratosis vs, 205f desmoplastic, 137f
see also under Hemangioma skin-colored nodule, 89f diagnosis by 3-checklist, 1–32
Lattice-like pattern see under Acral Spitz nevus vs, 77f, 202f diagnosis by five melanoma-specific
melanocytic lesions vascular patterns, 205f local criteria see Melanoma-
Lentigo annular-granular structures, 96f specific criteria below
inkspot see Inkspot lentigo gray granules, 95f differential diagnosis
solar see Solar lentigo appearance of new structures, 175f acral melanocytic lesion vs,
unstable, 94f arising in nevus, 83f 101f
Lentigo maligna asymmetrically pigmented follicles, basal cell carcinoma vs, 11f, 78,
actinic keratosis vs, 99f 94f, 96f 88f, 94f, 108f, 110f, 112f, 114f,
annular-granular structures, 95f asymmetry of color/structure, 1, 2t, 116f, 117f, 153f, 154f, 202f,
asymmetry of color/structure, 183f 3f, 4f, 5f, 7f, 8f, 9f, 10f, 11f, 13f, 204f
classical pattern of early, 96f 15f, 16f, 18f, 19f, 21f, 22f, 23f, blue nevus vs, 27f, 64f, 66f, 67f,
facial, 94f, 95f, 96f 30f, 79f, 80f, 82f, 83f, 85f, 86f, 155f
gray pseudonetwork, 94f, 181f 90f, 92f, 96f, 179f, 202f, 208f, Clark (dysplastic) nevus vs, 21f,
melanocytes, 95f 210f 69f, 83f, 87f, 88f, 91f
227
Melanoma (Continued) Melanoma (Continued) Melanoma (Continued)
combined nevus vs, 39f, 77f, 167f, irregular streaks, 5f, 78, 79f, 80f, 81f, streaks, 151f, 159f, 161f
210f 82f, 83f, 86f, 88f, 89f, 92f, 154f, irregular see above
hemangioma vs, 130f, 131f, 132f 159f, 162f, 163f square, 142f
inkspot lentigo vs, 151f absent, 91f subungual, 193f
nevus spilus vs, 60f basal cell carcinoma vs, 114f superficial see Superficial melanoma
nevus vs, 38f, 60f, 61f, 64f, within blotch, 81f traumatized, 166f
169f in five positive criteria, 78 ‘ugly duckling’ lesion, 171f, 209f
seborrheic keratosis vs, 6f, 84f, irregular vessels, 202f, 203f ulceration, 132f
85f, 91f, 127f, 202f, 203f irritated, 84f verrucous, 90f
Spitz nevus vs, 12f, 69f, 70f, 71f, lentigo maligna see Lentigo maligna vulval, 199f
72f, 74f, 75f, 76f, 77f, 202f line segmentation, broken-up, 5f white color, 208f, 209f
distinguishing criteria, 1, 3f, 7f melanoma-specific criteria, 79f, 80f, yellowish globules, 8f
dots and globules 81f, 82f, 83f, 84f, 85f, 86f, 87f, Melanophages
cobblestone-like shape, 140f 88f, 89f, 90f, 91f, 92f, 142f, blue-white structures, 78
irregular see below 151f, 158f dots and globules, 78
small red dots, 209f identification of, 146f black and bluish pepper-like,
dotted vessels, 203f site-specific, 94f, 95f, 96f, 97f, 98f, 85f
early, 18f, 76f, 169f 99f infiltrate, 35f
eccentric area, 91f metastatic inkspot lentigo, 149f
EGF (Elevated Firm Growing) rule, blue nevus vs, 27f, 64f, 155f lichen planus-like keratosis, 183f
207 mimicking hemangioma, 130f nevus (nevi), 35f
enlargement, 175f milia-like cysts, 107 regressing melanoma, 61f, 209f,
featureless, 6f, 83f, 91f, 107 milky-red background, 203f 210f
fibrosis, 178f multicomponent global pattern, 78, Meyerson nevus, 165f
follicular ostia, 95f 79f, 82f, 83f, 85f, 86f Microarborizing vessels, basal cell
gray pseudonetwork, 93–99, 95f in nevus spilus, 62f carcinoma, 110f, 116f
gray zone, 81f nodular Milia-like cysts
hairpin vessels, 202f basal cell carcinoma vs, 109f, 112f, blue nevus, 155f
hypomelanotic 117f, 153f dermatofibroma, 136f
arising within superficial blue nevus vs, 27f, 64f, 155f description, 107
melanoma or pre-existing Clark on face, 153f follicula ostia vs, 95f
nevus, 39f hypomelanotic, arising within a melanoma, 91f, 182f
basal cell carcinoma vs, 113f superficial melanoma/pre- nevus, 43f, 53f, 60f
blue nevus vs, 66f existing Clark nevus, 39f dermal, 201f
hypopigmentation, 91f, 171f, 210f skin-colored, 89f seborrheic keratosis, 6f, 8f, 43f, 53f,
information, keeping from patients, Spitz nevus vs, 67f, 76f 91f, 94f, 107, 118f, 119f, 120f,
159f thin and ulcerated, 84f 121f, 122f, 123f, 124f, 139, 182f
invasive, 154f parallel-ridge pattern, acral Milky-red background
irregular blotches, 81f, 82f, 84f, 85f, melanoma, 106f melanoma, 203f
89f, 91f, 146f patchy reticular pattern, 87f Spitz nevus, 141f, 202f
blue-gray, 140f pigment network, 91f warning, 141f, 203f
brownish, 87f absence of, 9f, 13f, 30f, 84f, Moth-like appearance, solar lentigo,
in five positive criteria, 78 91f 80f, 97f, 98f, 181f
grayish, 208f, 210f atypical, see above Mucosal lesions
horeshoe-shaped, 163f pink color, 82f, 96f, 163f, 179f, 208f, general dermoscopic principles,
irregular streaks within, 81f 209f, 210f 196–199
melanoma-specific criteria, 158f reddish color, 84f, 171f genital nevus, 199f
spitzoid lesion, 90f reflection artifact, 81f labial lentigines, 198f
irregular dots and globules, 78, 79f, regression, 177f, 178f, 179f labial lentigo, 197f, 198f
80f, 81f, 82f, 83f, 84f, 86f, 88f, blue nevus vs, 65f melanoma of vulva, 199f
89f, 91f, 92f, 96f, 142f, 151f, bony white areas, 36f, 38f, 41f venous lake, 197f
154f, 159f, 161f, 175f multifocal hypopigmentation Multiple Clark (dysplastic nevi),
acral lesions, 190f verging on, 171f 168–171
black, 85f, 88f nevus vs, 36f, 61f
bluish ‘pepper-like’ dots, 85f in superficial melanoma, 86f, 92f, N
brownish, 87f 176 Nail-apparatus melanoma (NAM), 192
in five positive criteria, 78 rhomboid structures, 93, 96f Hutchinson’s sign, 195f
melanoma-specific criteria, 158f in situ see In situ melanoma masquerading as blood, 194f
reddish dots, 208f as spitzoid lesion, 90f, 92f, 161f, Nails, pigmented lesions
seborrheic keratosis vs, 85f 162f, 163f general dermoscopic principles,
spitzoid lesion, 90f starburst pattern, 161f 192–195
vulva, melanoma of, 199f statistical analysis, 1 hemorrhage, 193f, 194f
228
Nails, pigmented lesions (Continued) Nevus (nevi) (Continued) Nevus (nevi) (Continued)
Index
nail-apparatus melanoma, 192, Clark (dysplastic) nevus, 35f, 48f, hypopigmentation, 38f
195f 157f, 170f central, 29f
masquerading as blood, 194f closely packed, 43f, 46f homogeneous, 36f
nevus (nevi), 195f cobblestone-like shape, 46f, 140f multifocal, 21f, 58f
Nevus (nevi) and comedo-like openings, 54f hypopigmentation islands, 34f, 58f
acral see Acral melanocytic lesions dark-brown, 35f, 46f, 57f hypopigmented areas, 37f, 59f
asymmetry of color/structure, 4f, 6f, dermal nevi, 186f intradermal, 107
8f, 17f, 20f, 26f, 27f, 28f, 29f, exophytic papillary structures/ irregular blotches, 53f, 59f
31f, 48f, 63f ridges resembling globules, 56f irritated, 56f
slight, 12f, 14f, 21f, 25f, 26f, 41f flat brownish area with, 55f junctional
atypical see Clark (dysplastic) nevus globular pattern, 43f Clark (dysplastic) nevus, 40f
atypical pigment network, 14f, 20f, irregular, brownish, 48f compound, difficult to
26f, 27f, 28f, 29f, 30f, 51f numerous, 43f, 58f differentiate, 34f, 35f, 43f
absent, 4f, 17f, 22f, 23f, 28f regular, 146f parakeratosis, 211
see also Pigment network below reticular pattern, 35f line segmentation, pigment network
black, 28f rim of brown pigmentation see under Line segmentation,
reticular-homogenous pattern, 52f surrounding, 46f pigment network
tape stripping, 52f slightly irregular, 51f melanoma arising within, 83f
tape test, 211 subtle, 44f melanoma features, none seen, 32f
blue see Blue nevus tiny dots, central part, 50f Meyerson, 165f
blue-white structures, 12f, 23f, 31f uneven distribution, 44f, 48f milia-like cysts, 43f, 53f, 60f
absent, 4f, 6f, 7f, 8f, 12f, 14f, 17f, see also Globular pattern below movement from side to side, 55f
22f, 26f, 28f, 29f, 30f dysplastic see Clark (dysplastic) multifocal hypopigmentation, 21f,
bluish dots and globules confused nevus 58f
with, 54f enlargement, 173f multiple nevi, 168–171, 169f
diffuse, 35f evolving, 173f follow-up, 175f
present, 20f, 24f, 25f, 28f, 50f, 51f, exophytic papillary structures/ridges, nail-apparatus pigmentation, 195f
57f, 60f, 146f 56f, 60f papillomatous dermal, 55f, 56f
slight, 18f intermingled with furrows, 57f comedo-like openings, 55f, 60f
subtle, 55f featureless, 56f papillomatous surface, 46f, 54f
borderline lesion, 23f flat melanocytic, 34f, 55f, 58f paracentral hyperpigmentation, 41f
central hypopigmentation, 29f, 41f follow-up, 40f, 42f, 47f, 49f, 51f, 52f pediatric patients see under Pediatric
Clark (dysplastic) see Clark congenital nevus, 63f patients
(dysplastic) nevus genital, 199f pigmentation, dark brown, 47f
cockade, 167f globular-homogenous pattern, 57f, pigment network, 21f
color variation, 46f 60f absent, 6f, 12f, 14f, 18f, 20f, 25f
combined see Combined nevus globular pattern, 44f, 46f, 47f, 53f, central-periphery distinctions,
comedo-like openings, 54f, 55f, 56f, 54f, 55f, 56f, 57f, 59f, 61f, 63f 49f
60f basal cell carcinoma vs, 53f fading out at periphery, 34f, 36f,
comma-like vessels, 53f, 55f Clark (dysplastic) nevus, 48f 37f, 41f, 42f, 52f, 127f
common, in men, 42f dark brown pigmentation, 47f patchy, 63f
compound, 46f description, 33 regular, 3f, 7f
junctional, difficult to melanoma arising within nevus, small rim surrounding
differentiate, 34f, 35f, 43f 83f homogeneous
congenital see Congenital overlap of features, 49f hypopigmentation, 36f
melanocytic nevus with reticular pattern, 57f typical, 8f, 12f, 24f, 29f, 34f, 35f,
crypts and furrows, irregular, 56f stereotypical, 43f, 46f 36f, 37f, 41f, 52f, 146f
dark color, 7f, 12f, 23f variations, 43f, 45f, 51f uneven distribution, 37f
dermal see Dermal nevus see also Dots and globules above see also Atypical pigment network
differential diagnosis globules, 20f, 25f above
basal cell carcinoma vs, 25f, 53f, gray zone lesions, 51f pink color, 40f, 48f
56f hemosiderotic targetoid, 166f pseudopigment network, 62f
hemangioma vs, 64f holes representing hair follicles, 57f recurrent, 166f
melanoma vs, 38f, 60f, 61f, round white, 59f Reed (Spitz) see Spitz nevus
64f, 169f homogeneous pattern, 56f, 64f regular pigment network, 3f, 7f
in situ melanoma vs, 30f, 52f blue nevus, 64f, 65f reticular-globular pattern, 39f, 49f,
dots and globules, 43f, 53f bluish pigmentation, 66f, 67f 50f
black (Spitz nevus), 73f diffuse pigmentation, 50f reticular-homogenous pattern, 36f,
bluish, 54f, 59f genital nevus, 199f 40f, 41f, 51f, 52f, 63f
brownish, 57f, 59f reticular, 41f Clark (dysplastic) nevus, 38f
brownish-blue, 53f, 61f, 69f variation in colors, 64f stereotypical reticular, 37f
brown-to-gray, 47f hyperpigmentation, paracentral, 41f variation, 38f
229
Nevus (nevi) (Continued) Parallel-ridge pattern Pigment network (Continued)
reticular pattern, 42f, 58f, 61f acral melanocytic lesions see Acral negative, in Spitz nevus, 69f
atypical pigment network and, melanocytic lesions nevus (nevi)
42f, 61f vs fibrillar pattern, 104f nevus spilus, 62f
common, in flat acquired malignant nature of, 102f patchy, 37f
melanocytic nevus, 34f melanoma see Melanoma see also under Nevus (nevi)
globular pattern with, 57f vs parallel-furrow pattern, 102f, pseudopigment network vs, 62f
nevus spilus, 62f 106f reticular pattern, 33
patchy, 37f as removal criterion, 106f see also Reticular pattern
pseudopigment network, 62f subcorneal hemorrhage, 213f Spitz nevus see under Spitz nevus
stereotypical, 52f Pattern analysis, 33–138 uneven distribution, 37f
seborrheic keratosis adjacent Pediatric patients Pink color
to, 90f congenital melanocytic nevus, 140f actinic keratosis, 99f
sessile nodule, 54f follow-up of lesions, 172 basal cell carcinoma, 110f, 115f,
soft compressible nature, 54f, 55f, general dermoscopic principles, 116f, 117f
56f, 60f 139–143 dermatofibroma, 137f
Spitz see Spitz nevus giant congenital melanocytic nevus, keratoacanthoma, 187f
starburst pattern, streaks with, 33 139 melanoma see Melanoma
stereotypical, 12f, 43f melanoma, 142f nevus (nevi), 40f, 48f
streaks, 50f nevus (nevi) dermal, 185f
Sutton, 165f on back, 143f Spitz nevus, 77f, 141f
symmetrical, 3f, 7f, 18f, 25f, 28f, 36f, dysplastic see Clark (dysplastic) seborrheic keratosis, 126f, 127f
41f, 59f, 61f, 62f, 63f, 146f nevus Spitz nevus, 202f
traumatized, 166f globular pattern, 47f warning, 48f, 77f, 110f, 137f, 185f
yellowish-white keratotic material, reticular-homogenous pattern, 36f Polarized dermoscopy, 1
56f Spitz nevus, 74f, 139, 141f, 142f, Pseudonetwork
Nevus spilus, 60f 174f brown, 97f, 99f, 125f, 142f
melanoma in, 62f typical, 47f gray
Non-melanocytic lesions see also Adolescents lentigo maligna, 94f, 181f
basal cell carcinoma see under Basal Pigmentary incontinence, seborrheic melanoma, 93–99
cell carcinoma keratosis, 205f seborrheic keratosis, 119f
Bowen’s disease, 200 Pigmentation Pseudopigment network, seborrheic
dermatofibroma, 135f blue nevus see Blue nevus keratosis, 122f
seborrheic keratosis see Seborrheic dark brown nevus, 47f Pseudostarburst pattern, seborrheic
keratosis nail-apparatus, 195f keratosis, 119f
six diagnostic criteria, 107–137 rim of brown, 46f Punch biopsy, labial lentigines, 198f
see also Fibroangioma; Hemangioma; blue nevus, 64f Purple color
Kaposi’s sarcoma; Pyogenic see also Depigmentation; hemangioma, 128f, 133f
granuloma Hyperpigmentation; hemorrhage, 193f
Hypopigmentation; Pigment Pyogenic granuloma
O network fibroangioma vs, 130f
Orthokeratosis, blue-white structures, Pigmented lesions fibrosing, 134f
78 of nails see Nails, pigmented lesions hemangioma vs, 134f
Ostia of appendages of skin, triage, 1–32 red lacunas, 133f
head and neck lesions, 8f see also under Spitz nevus
melanoma, 94f Pigmented Skin Lesion Clinics, 198f R
Pigment network Recurrent nevi, 166f
P absent Red-blue lacunas
Papillomatous dermal nevi, 55f, 56f basal cell carcinoma, 19f description, 107
comedo-like openings, 54f, 55f, 60f, nevi, 6f, 18f, 20f, 28f hemangioma, 107, 129f, 131f,
107 seborrheic keratosis, 24f 134f
seborrheic keratosis vs, 123f atypical see Atypical pigment Reddish dots and globules, seborrheic
Papillomatous melanocytic nevi, network keratosis, 124f, 127f
seborrheic keratosis vs, 118f Clark (dysplastic) nevus see Clark Reddish-whitish color, fibroangioma,
Papillomatous surface, nevi, 46f, 54f (dysplastic) nevus 130f
Parallel-furrow pattern congenital melanocytic nevus, 58f Red lacunas
acral melanocytic lesions see Acral dermatofibroma, 135f, 136f, 137f fibroangioma, 130f
melanocytic lesions fading out hemangioma, 128f
benign nature of, 102f Clark (dysplastic) nevus, 35f Kaposi’s sarcoma, 134f
vs parallel-ridge pattern, 102f, 106f nevus, 34f, 36f, 37f, 41f, 42f, 52f, pyogenic granuloma, 133f
Parallel pattern, acral melanocytic 127f Reed nevus see Spitz nevus
lesions see under Acral line segmentation see Line Reflectance confocal microscopy, 96f
melanocytic lesions segmentation, pigment network Reflection artifacts, white dots, 81f
230
Regression in lesions Seborrheic keratosis (Continued) Solar lentigo (Continued)
Index
bony white areas, 36f, 38f, 41f brown pseudonetwork, 125f pigmentation, 97f, 98f
Clark (dysplastic) nevus, 65f, 177f, comedo-like openings, 107, 118f, seborrheic keratosis arising from,
178f, 179f 119f, 120f, 121f, 122f, 123f, 125f
general dermoscopic principles, 124f, 125f, 126f, 147f, 205f Special nevi
176–179 absent, 127f cockade, 167f
melanoma see under Melanoma differential diagnosis combined see Combined nevus
scarring and, 204f amelanotic melanoma vs, 205f definition, 164
Reticular depigmentation basal cell carcinoma vs, 110f, 124f, general dermoscopic principles,
dermatofibroma, 136f 127f 164–167
Spitz nevus, 77f, 141f dermatofibroma vs, 136f hemosiderotic targetoid, 166f
Reticular-global pattern, Clark lentigo maligna vs, 124f, 139 Meyerson nevus, 165f
(dysplastic) nevus, 39f melanoma vs, 6f, 84f, 85f, 91f, recurrent, 166f
Reticular-globular pattern 127f, 139, 202f, 203f Sutton nevus, 165f
Clark (dysplastic) nevus, 39f papillomatous dermal nevi vs, 123f Spindle cell nevus Reed (Spitz nevus),
nevus (nevi), 49f, 50f papillomatous melanocytic nevi 70f
Reticular-homogenous pattern, 41f vs, 118f Spitz nevus
Clark (dysplastic) nevus, 38f Spitz nevus vs, 119f asymmetry, 72f, 74f, 75f
nevus (nevi), 36f, 40f, 51f, 52f superficial melanoma vs, 125f atypical, 13f, 142f
patchy, 63f facial, 99f, 126f blood vessels, 69f, 141f, 202f
stereotypical reticular, 37f ‘fat fingers,’, 99f, 125f blotches, 163f
variation, 38f flat lesion, 118f, 119f, 122f, 182f blue-white structures, 13f, 68f, 70f,
Reticular lesions follicular openings, 85f, 126f, 139 73f, 74f, 75f, 78, 147f, 158f,
Clark (dysplastic) nevus, 157f, 158f hairpin vessels, 205f 161f, 162f
see also Clark (dysplastic) nevus hypopigmentation, 121f blotch partially covering, 163f
general dermoscopic principles, irritated, 84f, 126f, 205f in child, 74f
156–159 keratotic, adjacent to benign nevus, combined pattern, 77f
melanoma, 157f, 159f 90f differential diagnosis
see also Melanoma milia-like cysts, 6f, 8f, 43f, 53f, 91f, basal cell carcinoma vs, 112f
Spitz nevus, 158f 94f, 107, 118f, 119f, 120f, 121f, blue nevus vs, 67f
see also Spitz nevus 122f, 123f, 124f, 139, 182f Clark (dysplastic) nevus vs, 12f,
Reticular pattern absent, 127f 50f, 69f, 71f, 73f
acral melanocytic lesions, 103f multicomponent global pattern, 78 dermatofibroma vs, 137f
description, 33 opaque color, 120f melanoma vs, 12f, 69f, 70f, 71f,
melanoma, 87f pigmentary incontinence, 205f 72f, 74f, 75f, 76f, 77f, 147f, 202f
nevus see Clark (dysplastic) nevus; pigment network pigmented spindle cell nevus
Nevus (nevi) absent, 24f Reed, 147f
patchy, 37f, 87f diffuse area, 124f seborrheic keratosis vs, 119f
Reticular-starburst pattern, Spitz nevus, pink color, 126f, 127f in situ melanoma vs, 70f, 73f
76f, 158f reddish dots, 124f, 127f diffuse homogeneous pigmentation,
Rhomboid structures reticular pattern, 127f 50f
description, 93 rhomboid structures, 182f dots and globules, rim of, 161f
lentigo maligna, 94f, 95f, 119f, 183f solar lentigo, arising from, 125f fatalities, 160
lentigo maligna melanoma, 95f stereotypical, 122f, 123f flat nonpigmented, 141f
melanoma, 78 streaks, 147f follow-up, 174f
seborrheic keratosis, 182f stuck-on appearance, 123f globular-homogenous pattern, 77f
Rim of brown pigmentation, blue superficial, 124f brownish dots/globules, 75f
nevus, 64f variations, 123f globular pattern/type, 69f, 71f
verrucous surface, 120f black, 75f
S Shave biopsy dots and globule size variations,
Scrape test, 167f Clark (dysplastic) nevus, 48f 75f
subcorneal hemorrhage, 213f labial lentigo, 197f mimicking melanoma, 74f
Seborrheic keratosis seborrheic keratosis, 123f, 126f, 205f prominent dots and globules, 69f
acanthotic type, 123f, 205f Soft compressible nature, nevus, 54f, uneven distribution, 76f
actinic lentigo, evolving from, 99f 55f, 56f, 60f globular-starburst pattern, 73f
annular-granular structures, 182f Solar lentigo homogeneous areas, 142f
asymmetry, 6f, 99f, 120f, 123f, 124f, asymmetry of color, 80f, 181f homogeneous central zone, 75f
126f, 182f on face, 181f homogeneous-starburst pattern, 72f,
slight, 24f lentigo maligna vs, 94f 73f
blood vessels, 205f melanoma-specific criteria, lack of, irregular dots and globules, 75f, 76f
blue-gray blotches, 127f 98f life cycle, 71f
blue-white structures, 24f, 121f, 123f moth-like appearance, 80f, 97f, 98f, management approach, 139
bluish color, 126f 181f melanoma suspicion, 69f
231
Spitz nevus (Continued) Streaks (Continued) Tattoos, 64f
milky-red background, 141f, 202f irregular Technique (dermoscopy), 1
non-pigmented, 202f description, 78 Telangiectasias, pyogenic granuloma,
pigmentation, black-bluish, 141f melanoma see under Melanoma 133f
pigmented spindle cell nevus Reed, seborrheic keratosis, 125f Tests, dermoscopy
70f, 71f, 74f, 139, 141f, 147f, regular, 99f blanching, 211
174f seborrheic keratosis, 125f, 147f general dermoscopic principles,
pigment network, 71f, 76f Spitz nevus, 50f, 68f, 69f, 70f, 71f, 211–215
absent, 75f 72f, 73f, 74f, 76f, 78, 141f, 147f, scrape test, 167f
atypical, 13f 158f, 161f, 162f, 174f tape test, 211, 212f
jet black, 72f ‘String of pearls’ white dots, acral wobble sign, 169f
multiple colors, 73f, 74f melanocytic lesions, 101f, 103f, Thigh, Spitz nevus on, 141f
negative, 69f, 77f 106f, 189f, 190f 3-point checklist, 1–32
reticular depigmentation, 77f Structure, asymmetry of see Asymmetry see also Asymmetry (color or
superficial black, 70f, 72f, 76f (color or structure) structure); Atypical pigment
variation, 71f Subcorneal hematoma, red-blue network; Blue-white structures
pink color, 77f, 141f, 202f lacunas, 107 Total-body photography, melanoma
reddish color, 141f, 142f Subcorneal hemorrhage, 191f recognition, 172
Reed see above under pigmented scrape test, 213f Traumatized nevi, 166f
spindle cell nevus Reed Subungual hematoma, red-blue Triage, pigmented skin lesions, 1–32
reticular depigmentation, 77f, 141f lacunas, 107
reticular-starburst pattern, 76f, 158f Subungual hemorrhage, 193f U
starburst pattern, 68f, 70f, 72f, 74f, Subungual melanoma, 193f ‘Ugly duckling’ lesion, 168, 171f, 209f
139, 163f Sun damage Ulceration
basal cell carcinoma contrasted, lentigo maligna and, 94f basal cell carcinoma, 110f, 111f,
112f melanoma findings, 80f 112f, 113f, 115f, 132f, 153f,
dots and globules with, 33 seborrheic keratosis, 122f, 125f 154f
with eccrine duct openings, 71f Superficial melanoma melanoma, 132f
globular pattern compared, 160 asymmetry, 84f, 87f, 92f, 210f Unstable lentigo, concept, 94f
seborrheic keratosis contrasted, atypical pigment network, 92f
119f blue-white structure, 84f
V
streaks with, 33 blue-white structures, 92f Vascular patterns see Blood vessels
variant nevus, 70f, 72f Clark (dysplastic) nevus vs, 84f Venous lake, 197f
stereotypical, 68f comedo-like openings, 120f
Vulva, melanoma of, 199f
streaks, 50f, 68f, 69f, 70f, 71f, 72f, hypomelanotic nodular melanoma
73f, 74f, 76f, 78, 141f, 147f, arising within, 39f
158f, 161f, 162f, 174f irregular blotches, 86f, 87f W
symmetrically located, 163f irregular dots and globules, 84f, 92f White color
symmetrical, 69f, 70f, 75f, 161f, 162f brownish to black, 87f in blue-white structures, 21f, 25f
variant, starburst pattern, 70f irregular streaks, 84f, 86f, 87f, 92f central white patch see Central white
see also Spitzoid lesion milia-like cysts, 120f patch
Spitzoid lesion with regression, 86f, 92f, 176, 177f dermatofibroma, 136f
asymmetry, 90f seborrheic keratosis vs, 120f, 125f hemangioma, 128f
differential diagnosis, 160 see also Melanoma keratoacanthoma, 204f
general dermoscopic principles, 160 Sutton nevus, 165f melanoma see Melanoma
melanoma as see under Melanoma Symmetry of color and structure, nevi, White dots
recognition of symmetry/asymmetry 3f, 7f, 18f, 25f, 28f, 36f, 41f, 59f, acral lesions, 189f
in, 162f 61f, 146f acral melanocytic lesions
Squamous cell carcinoma, 187f blue nevus, 27f lattice-like pattern, 101f, 103f
Starburst pattern congenital, 62f, 63f parallel-furrow pattern, 102f
description, 33–77 Spitz nevus, 69f, 70f, 75f, 161f, 162f actinic keratosis, 97f
melanoma, 161f reflection artifacts, 81f
Spitz nevus see Spitz nevus T Wobble sign, 169f
Steroid treatment, Meyerson nevus, Tape stripping
165f black lamella, 36f Y
Streaks black nevus, 52f Yellow color
chrysalis-like structures, melanoma, Tape test, 211 keratotic material, nevus, 56f
5f, 88f black nevus, 212f melanoma, 8f
hemorrhage, 187f Targetoid composition, melanoma, 96f seborrheic keratosis, 126f
232
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DERMOSCOPY

H. Peter Soyer, MD, FACD

First edition 2004

British Library Cataloguing in Publication Data

Dermoscopy : the essentials. – 2nd ed.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

1 INTRODUCTION – THE 3-POINT CHECKLIST 1

3 COMMON CLINICAL SCENARIOS 139

Further reading 217

KEY TO TRAFFIC LIGHT SYMBOLS

High risk lesions

Moderate risk lesions

Low risk lesions

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Figure 7 Seborrheic keratosis

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Figure 15 Basal cell carcinoma

Introduction: The 3-point checklist

Figure 17 Basal cell carcinoma

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Figure 26 Basal cell carcinoma

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Figure 34 Basal cell carcinoma

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Figure 44 Seborrheic keratosis

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Figure 57 Basal cell carcinoma

Figure 60 Basal cell carcinoma

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Figure 100 Nevus

Figure 101 Nevus

Four global patterns