Enhancing Skin Cancer Diagnosis with Dermoscopy

Abstract

Dermoscopy increases the sensitivity for skin cancer detection, decreases the number of benign lesions biopsied for each malignant diagnosis, and enables the diagnosis of thinner melanomas compared with naked eye examination. Multiple meta-analyses have identified that dermoscopy improves the diagnostic accuracy for melanoma when compared with naked eye examination. In addition, studies have established that dermoscopy can aid in the detection of keratinocyte carcinomas. Dermoscopy triage algorithms have been developed to help novices decide when a biopsy or a referral is most appropriate. In this article, the authors illustrate the dermoscopic features that assist in identifying melanoma and keratinocyte carcinomas.

Keywords: Dermatoscopy; Dermoscopy; Diagnostic accuracy; Keratinocyte carcinomas; Melanoma; Odds ratio; Sensitivity; Specificity.

Fig. 1

Dermoscopic features of melanoma. (A) Melanoma presenting with atypical globules and dots of different sizes and shapes (yellow arrows), patches of atypical network (blue arrowhead) and a blue-white veil (blue arrow). (B) Melanoma with diffuse polymorphous vasculature, consisting of serpentine, dotted, and glomerular vessels, can be found throughout the lesion (yellow arrowheads). In addition, patches of atypical network (blue arrowheads) are seen. (C) Superficial spreading melanoma with pseudopods distributed asymmetrically around the lesion (black arrowheads). (D) Melanoma with the regression structure blue-grey peppering (black star). Shiny white lines are also seen throughout the entire lesion (red arrows) along with a central blue-white veil (red arrowhead).

Fig. 2

Dermoscopic features of melanoma in special locations. (A) Lentigo maligna melanoma on the face with concentric circles, also know as circle within a circle (blue arrowhead), grey circles (blue arrow), incomplete circles (black arrowhead), and angulated lines (black star. Within the melanoma, there is a seborrheic keratosis (black arrow) with comedo-like openings. (B) Melanoma of the nail matrix with brown lines that vary in thickness and have a disruption in parallelism. The patient has distal onycholysis. (C) Melanoma of the vulva with a linear pattern with features resembling a negative network (red asterisk). Yet, shiny white structures (red arrow) and multiple shades of brown with asymmetric distribution of pigment are indicative melanoma. (D) Acral lentiginous melanoma on the volar skin of the heel with pigment on the ridges (red arrowheads).

Fig. 3

Dermoscopic features of basal cell carcinoma. (A) Pigmented basal cell carcinoma with leaf-like structures (black arrow) and blue-grey ovoid nests, globules, and dots (blue arrows). (B) Nodular basal cell carcinoma with an arborizing vessel (yellow arrow) and blue-grey dots and globules (blue arrows). (C) Nonpigmented superficial basal cell carcinoma with shiny white blotches and strands (yellow arrowheads) and short fine vessels (blue arrowhead). (D) Superficial basal cell carcinoma with multiple erosions/ulcerations (white arrows) over an erythematous background with polymorphous vessels.

Fig. 4

Dermoscopic features of keratinizing skin cancers. (A) Squamous cell carcinoma showing diffuse polymorphous vasculature consisting of numerous serpentine (black arrow), dotted (blue arrow), and looped vessels (yellow arrow). A triangular ulceration (yellow arrowhead) with associated scale (blue arrowhead) is also seen. (B) Keratoacanthoma presenting with a central keratin plug and a peripheral rim of irregular looped (red arrowheads) and serpentine vessels (black arrowhead). (C) Pigmented squamous cell carcinoma with numerous rosettes (white arrows). (D) Actinic keratosis with a strawberry pattern consisting of a structureless red area interrupted by the follicular openings.

Fig. 5

Triage amalgamated dermoscopic algorithm (TADA) is a multistep process to guide dermoscopic management of skin lesions. First, unequivocal angiomas, dermatofibromas, and seborrheic keratoses are identified and excluded from further evaluation. Next the lesion is evaluated for the presence of architectural disorder or order. If architectural disorder is present, the lesion should be biopsied or referred for further management. On rare occasion a malignancy can present in an organized fashion, thus all organized lesions are then evaluated for blue-black or gray color, white structures, negative network, ulcer/erosion, starburst pattern and/or vessels. The presence of any one of these features would raise concern for malignancy. (*) Lesions of the volar surfaces, nails, mucosal surfaces, and face should not be evaluated with this algorithm. Courtesy of Natalia Jaimes, MD, Miami, FL; Zachary J. Wolner, BA, Oriol Yelamos, MD, Konstantinos Liopyris, MD, Tova Rogers, MFA, Michael A. Marchetti, MD, Ashfaq A. Marghoob, MD, New York, NY.