The BRAAFF checklist: a new dermoscopic algorithm for diagnosing acral melanoma

A clinical-dermoscopic risk scoring model for early melanoma of the soles: The iDScore_plantar

BACKGROUND

Melanoma of the sole is an aggressive rare form, often diagnosed late. Plantar atypical nevi (pAN) are frequently misdiagnosed as plantar early melanomas (pEM) and therefore excised. Our aim was to develop a clinical-dermoscopic risk-scoring model to help discriminate these plantar atypical melanocytic lesions (pAMLs).

MATERIALS AND METHODS

We collected 490 pAMLs (98 pEM, 392 pAN) paired with histopathological diagnosis, dermoscopic and clinical image, maximum lesion diameter, plantar location and age and sex of the patient from 17 European centres. This plantar dataset was grouped into training (261), validation (174) and testing (55 pAMLs) subsets. European participants (104 dermatologists, 56 residents) performed a blinded tele-dermoscopic test, including intuitive diagnosis, pattern analysis, rating of case difficulty, diagnostic confidence assessment and management decision.

RESULTS

A total of 2887 dermoscopic evaluations were obtained. The iDScore_plantar model gave an average area under the receiver operating characteristic curve of 0.95 (against 0.77 for pattern analysis). It was composed of the sum of five scores (S) for the following items: maximum diameter 8-12 (S = 1)/>12 mm (S = 5); age 40-50 (S = 2)/>50 years (S = 5); location on heel (S4) or on toes/plantar eminence (S = 2); asymmetry of colours (S = 2) and/or asymmetry of structures (S = 1). 'Long/short follow-up, biopsy, excision' decisions were matched with four risk ranges: no risk (S = 0-3), low-medium risk (S = 4-8), medium-high risk (S = 9-12) and very high risk (S = 13-17). By applying the model, participants would have reduced the number of misdiagnosed pAN and the number of pAN excised by -25.5% and -27.7%, respectively, and would have increased the number of correctly diagnosed pEM by +18.5%, the number of pEM recommended for surgical excision by +8.5% and the number of pEM recommended directly for surgical excision instead of biopsy by +16.15%.

CONCLUSION

The iDScore_plantar model proved to be a simple scoring tool to help clinicians in assigning a progressive risk of malignancy to pAMLs.

Diagnostic Accuracy of Novel Optical Imaging Techniques for Melanoma Detection: A Systematic Review and Meta-Analysis

The incidence of melanoma is increasing worldwide, requiring early detection to improve survival rates. Although dermoscopy is the standard non-invasive tool for diagnosing melanoma, it relies on experience and skill. Advances in optical imaging technologies and artificial intelligence have the potential to improve diagnostic accuracy. Our objective was to compare the diagnostic accuracy of novel non-invasive optical imaging techniques for melanoma detection. A systematic literature search was conducted in three databases (Medline, Embase, and CENTRAL) on November 15, 2023. Inclusion criteria focused on studies comparing the accuracy of optical imaging methods against histopathology. Outcomes consisted of measures of diagnostic accuracy. Random-effects meta-analyses were performed for each method with 95% confidence intervals to summarize all relevant effect sizes. Of the 16,239 records, 141 articles met the inclusion criteria, of which 138 articles were eligible for the meta-analysis. Reflectance confocal microscopy (RCM) and dermoscopy combined with artificial intelligence (DSC + AI) had the highest sensitivity (0.93), with DSC + AI showing higher specificity (0.77 [0.70-0.83]) than RCM (0.749 [0.7475-0.7504]). Multispectral imaging combined with AI also showed high sensitivity (0.92 [0.82-0.97]) and relatively high specificity (0.80 [0.67-0.89]). Standalone dermoscopy exhibited balanced sensitivity (0.87 [0.84-0.90]) and specificity (0.82 [0.78-0.86]). In melanoma diagnosis, both RCM and DSC + AI can serve as second-step optical evaluation methods for suspicious lesions following initial screening with DSC. By maintaining a strong emphasis on multimodal imaging, healthcare providers could improve early detection and outcomes for patients with melanoma.

A cross-sectional study of physiologic volar melanotic macules: Demographic, historical, clinical, and dermatoscopic features of a common yet neglected pigmentary variant in individuals with skin of color

BACKGROUND

Physiologic volar melanotic macules (P-VMM) are understudied. Trauma has been suggested as a predisposing factor. Little has been published over the last several decades.

OBJECTIVE

The objective of this study was to evaluate the clinical/historical/dermatoscopic features of P-VMM in persons with skin of color (SOC).

METHOD

This cross-sectional study enrolled 200 adults with skin of color from Jamaica and Massachusetts. In those with P-VMM, clinical and dermatoscopic images were taken, with size, color, localization, distribution, and dermatoscopic patterns recorded. Questionnaires recorded demographic, occupational, and trauma history in both groups.

RESULTS

For those with P-VMM, most (91.8%, n = 89) were Black, followed by mixed-race (5.2%, n = 5), Indian Asian (2.1%, n = 2), and Hispanic (1%, n = 1). The F:M ratio was 2.5:1. Both palms/soles were involved in 67%. Light-to-dark brown, round/oval macules/patches were common and similar to each other. No significant difference in trauma was found, nor was there a predilection for weight-bearing areas. Occupations involving manual labor were associated with the presence of P-VMM (P = .019). Dermatoscopically, >90% had a homogeneous pattern, whereas bland ridge, beaded, and fibrillar patterns were rarely seen.

LIMITATIONS

Limitations of this study include the lack of histopathology and unbalanced proportions of skin of color subgroups.

CONCLUSION

P-VMM is common in Black adults. It lacks an association with major trauma or predilection for weight-bearing sites. Dermoscopy primarily reveals a homogeneous pattern.

Skin Cancer Diagnosis by Lesion, Physician, and Examination Type: A Systematic Review and Meta-Analysis

Importance

Skin cancer is the most common cancer in the US; accurate detection can minimize morbidity and mortality.

Objective

To assess the accuracy of skin cancer diagnosis by lesion type, physician specialty and experience, and physical examination method.

Data Sources

PubMed, Embase, and Web of Science.

Study Selection

Cross-sectional and case-control studies, randomized clinical trials, and nonrandomized controlled trials that used dermatologists or primary care physicians (PCPs) to examine keratinocytic and/or melanocytic skin lesions were included.

Data Extraction and Synthesis

Search terms, study objectives, and protocol methods were defined before study initiation. Data extraction was performed by a reviewer, with verification by a second reviewer. A mixed-effects model was used in the data analysis. Data analyses were performed from May 2022 to December 2023.

Main Outcomes and Measures

Meta-analysis of diagnostic accuracy comprised sensitivity and specificity by physician type (primary care physician or dermatologist; experienced or inexperienced) and examination method (in-person clinical examination and/or clinical images vs dermoscopy and/or dermoscopic images).

Results

In all, 100 studies were included in the analysis. With experienced dermatologists using clinical examination and clinical images, the sensitivity and specificity for diagnosing keratinocytic carcinomas were 79.0% and 89.1%, respectively; using dermoscopy and dermoscopic images, sensitivity and specificity were 83.7% and 87.4%, and for PCPs, 81.4% and 80.1%. Experienced dermatologists had 2.5-fold higher odds of accurate diagnosis of keratinocytic carcinomas using in-person dermoscopy and dermoscopic images compared with in-person clinical examination and images. When examining for melanoma using clinical examination and images, sensitivity and specificity were 76.9% and 89.1% for experienced dermatologists, 78.3% and 66.2% for inexperienced dermatologists, and 37.5% and 84.6% for PCPs, respectively; whereas when using dermoscopy and dermoscopic images, sensitivity and specificity were 85.7% and 81.3%, 78.0% and 69.5%, and 49.5% and 91.3%, respectively. Experienced dermatologists had 5.7-fold higher odds of accurate diagnosis of melanoma using dermoscopy compared with clinical examination. Compared with PCPs, experienced dermatologists had 13.3-fold higher odds of accurate diagnosis of melanoma using dermoscopic images.

Conclusions and Relevance

The findings of this systematic review and meta-analysis indicate that there are significant differences in diagnostic accuracy for skin cancer when comparing physician specialty and experience, and examination methods. These summary metrics of clinician diagnostic accuracy could be useful benchmarks for clinical trials, practitioner training, and the performance of emerging technologies.

Cyphellophora ludoviensis: a new causative species of tinea nigra

A case of tinea nigra caused by Cyphellophora ludoviensis.

European consensus-based interdisciplinary guideline for melanoma. Part 1: Diagnostics - Update 2024

This guideline was developed in close collaboration with multidisciplinary experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF) and the European Organization for Research and Treatment of Cancer (EORTC). Recommendations for the diagnosis and treatment of melanoma were developed on the basis of systematic literature research and consensus conferences. Cutaneous melanoma (CM) is the most dangerous form of skin tumor and accounts for 90 % of skin cancer mortality. The diagnosis of melanoma can be made clinically and must always be confirmed by dermoscopy. If melanoma is suspected, a histopathological examination is always required. Sequential digital dermoscopy and whole-body photography can be used in high-risk patients to improve the detection of early-stage melanoma. If available, confocal reflectance microscopy can also improve the clinical diagnosis in special cases. Melanoma is classified according to the 8th version of the American Joint Committee on Cancer classification. For thin melanomas up to a tumor thickness of 0.8 mm, no further diagnostic imaging is required. From stage IB, lymph node sonography is recommended, but no further imaging examinations. From stage IIB/C, whole-body examinations with computed tomography or positron emission tomography CT in combination with magnetic resonance imaging of the brain are recommended. From stage IIB/C and higher, a mutation test is recommended, especially for the BRAF V600 mutation. It is important to perform a structured follow-up to detect relapses and secondary primary melanomas as early as possible. A stage-based follow-up regimen is proposed, which in the experience of the guideline group covers the optimal requirements, although further studies may be considered. This guideline is valid until the end of 2026.

Melanoma in patients with skin of color

Cutaneous melanoma is far less common in skin of color patients than in non-Hispanic White individuals but carries a poorer prognosis. Melanomas in skin of color populations are more often identified on sun-protected locations such as acral surfaces, nail units, and mucous membranes, making them challenging to detect in early stages due to unfamiliar clinical and dermatoscopic features. Additionally, racial health care disparities compound the difficulty in diagnosis and ultimately contribute to poorer prognosis. We explore the epidemiology, clinical presentation, and health care disparities surrounding melanoma in skin of color individuals to increase awareness of the intricacies and nuances in identifying these malignancies.

Plantar acral melanoma: epidemiological, clinical, dermoscopic and histopathological features. A Brazilian cohort

BACKGROUND

Acral melanomas (AM) are rare and approximately two-thirds of them occur on the soles of the feet beeing more prevalent in black and Asian individuals. Data on this subtype of melanoma are scarce in the Brazilian population.

OBJECTIVES

To describe and correlate the epidemiological, clinical, dermoscopic, and histopathological features of AM a.

METHODS

Single-center, retrospective and cross-sectional study, evaluating data from a 15-year period.

RESULTS

A total of 48 cases were included. Mean age was 62.54 years, with a predominance of women (62.5%). The percentage of amelanotic melanomas was higher among lighter skin patients (20% × 7.7%). Polychromia was the most prevalent finding (94.4%). The parallel ridge pattern (PRP) had a prevalence of 78% and a serrated pattern was associated with lower Breslow thickness (p = 0.041). Ulceration present on histopathological (p = 0.013) or dermoscopic (p = 0.047) evaluation was associated with greater Breslow thickness.

STUDY LIMITATIONS

Retrospective study with loss of data.

CONCLUSION

Amelanotic tumors were more prevalent in ligther phototypes (20% × 7.7%). Polychromia was the most prevalent finding (94.4%) and ulceration observed on clinical or histopathological evaluation was associated with higher Breslow thickness (p = 0.013 and 0.047).

Acral and nail melanoma

Acral lentiginous melanoma (ALM) is a rare subtype of cutaneous malignant melanoma not linked to UV exposure that carries a poor survival prognosis. ALM is defined by its acral location, involving the palms, soles, and subungual regions of the hands and feet, as well as by its unique clinical characteristics. We have reviewed the incidence, diagnostic standards, histopathology, dermatoscopic features, reflectance confocal microscopy features, genomic alterations, and treatment of ALM. We highlight several recent case reports that showcase the diagnostic challenge that ALM poses and the barriers to arriving at a prompt and accurate ALM diagnosis. Increased patient and provider education, empowering early detection and treatment, as well as the development of new more targeted therapeutics are critical to improving ALM outcomes.

Validation of a Dermatoscopy-Based Algorithm for the Diagnosis of Acral Melanoma

INTRODUCTION

Diagnosis of acral melanocytic lesions can be challenging. The BRAAFF checklist was introduced as a tool to help differentiate between acral nevi and melanoma but has not been validated.

METHODS

We asked raters with varying expertise in dermatoscopy to diagnose dermatoscopic images of 533 acral nevi and 144 melanomas via an online platform with and without use of the BRAAFF checklist. From the ratings, we calculated sensitivity, specificity, and interrater agreement. Additionally, a new simplified version of the checklist was also tested.

RESULTS

We collected 6,880 ratings from 175 readers. The BRAAFF checklist achieved a sensitivity of 92.5% and a specificity of 65.0%, which was similar to diagnosis from pattern recognition (sensitivity 90.0%, specificity: 72.1%). Interrater agreement for the BRAAFF criteria ranged from fair to moderate, with lowest agreement for parallel ridge and fibrillar pattern (alpha = 0.31) and highest for asymmetry of colors and structures (alpha = 0.46). Agreement and diagnostic accuracy were higher for more experienced readers. A simplified version with only two criteria achieved similar sensitivity (95.0%) and lower specificity (60.0%) as the original BRAAFF checklist.

CONCLUSION

The BRAAFF checklist is a useful tool for the diagnosis of melanocytic acral lesions with acceptable sensitivity and reasonable specificity but is not superior to pattern recognition. A simplified version of the checklist could be easier to use with equal sensitivity while exhibiting a modest reduction in specificity.

A Narrative Review of the Evolution of Diagnostic Techniques and Treatment Strategies for Acral Lentiginous Melanoma

Acral melanoma (AM) is a subtype of cutaneous melanoma located on the palms, soles, and nails. The pathogenesis of AM involves mechanical stimulation and characteristic tumor-promoting mutations, such as those in the KIT proto-oncogene. Dermoscopy is useful for diagnosing AM, which is characterized by parallel ridge patterns and irregular diffuse pigmentation. Although histopathological confirmation is the gold standard for diagnosing AM, lesions showing minimal histopathological changes should be considered early-stage AM if they clinically resemble it. Recently, immunohistochemical staining of preferentially expressed antigen in melanoma has been recognized as a useful method to distinguish benign from malignant melanocytic tumors. Research reveals that AM is associated with an immunosuppressive microenvironment characterized by increased numbers of M2 macrophages and regulatory T cells, alongside a decreased number of tumor-infiltrating lymphocytes. Mohs micrographic surgery or digit-sparing wide local excision has been explored to improve quality of life and replace wide local excision or proximal amputation. AM has a worse prognosis than other subtypes, even in the early stages, indicating its inherent aggressiveness.

In Vivo Reflectance Confocal Microscopy Applied to Acral Melanocytic Lesions: A Systematic Review of the Literature

Background: Acral melanocytic lesions often pose a diagnostic and therapeutic challenge for many clinicians. Reflectance confocal microscopy (RCM) is an imaging technique widely used for the assessment of skin cancers. The aim of this review is to explore the applicability of RCM for the diagnosis of nevi and melanoma on the acral sites. Methods: Study selection was conducted based on the application of RCM for acral melanocytic lesions. All types of articles (original articles, short reports, and single case reports) were included in the analysis following PRISMA updated guidelines. Results: The search retrieved 18 papers according to the selection criteria; after removing duplicate records and additional articles by one or more of the exclusion criteria, a total of seven studies were carefully evaluated. Conclusions: RCM seems a valuable and useful additional tool for the diagnosis of acral melanocytic lesions, and its use may decrease the need for invasive procedures to some extent. Visualization of deeper layers may be achieved through mechanical removal of the superficial stratum corneum.

Pattern Analysis of Benign and Malignant Atypical Melanocytic Skin Lesions of Palms and Soles: Variations of Dermoscopic Features According to Anatomic Site and Personal Experience

Background: The differential diagnosis of atypical melanocytic skin lesions localized on palms and soles represents a diagnostic challenge: indeed, this spectrum encompasses atypical nevi (AN) and early-stage melanomas (EN) displaying overlapping clinical and dermoscopic features. This often generates unnecessary excisions or delayed diagnosis. Investigations to date were mostly carried out in specific populations, focusing either on acrolentiginous melanomas or morphologically typical acquired nevi. Aims: To investigate the dermoscopic features of atypical melanocytic palmoplantar skin lesions (aMPPLs) as evaluated by variously skilled dermatologists and assess their concordance; to investigate the variations in dermoscopic appearance according to precise location on palms and soles; to detect the features with the strongest association with malignancy/benignity in each specific site. Methods: A dataset of 471 aMPPLs-excised in the suspect of malignancy-was collected from 10 European Centers, including a standardized dermoscopic picture (17×) and lesion/patient metadata. An anatomical classification into 17 subareas was considered, along with an anatomo-functional classification considering pressure/friction, (4 macroareas). A total of 156 participants (95 with less than 5 years of experience in dermoscopy and 61 with ≥than 5 years) from 17 countries performed a blinded tele-dermoscopic pattern analysis over 20 cases through a specifically realized web platform. Results: A total of 37,440 dermoscopic evaluations were obtained over 94 (20%) EM and 377 (80%) AN. The areas with the highest density of EM compared to AN were the heel (40.3% EM/aMPPLs) of the sole and the "fingers area" (33%EM/aMPPLs) of the palm, both characterized by intense/chronic traumatism/friction. Globally, the recognition rates of 12 dermoscopic patterns were non statistically different between 95 dermatology residents and 61 specialists: aMPPLs in the plantar arch appeared to be the most "difficult" to diagnose, the parallel ridge pattern was poorly recognized and irregular/regular fibrillar patterns often misinterpreted. Regarding the aMPPL of the "heel area", the parallel furrow pattern (p = 0.014) and lattice-like pattern (p = 0.001) significantly discriminated benign cases, while asymmetry of colors (p = 0.002) and regression structures (p = 0.025) malignant ones. In aMPPLs of the "plantar arch", the lattice-like pattern (p = 0.012) was significant for benignity and asymmetry of structures, asymmetry of colors, regression structures, or blue-white veil for malignancy. In palmar lesions, no data were significant in the discrimination between malignant and benign aMPPLs. Conclusions: This study highlights that (i) the pattern analysis of aMPPLs is challenging for both experienced and novice dermoscopists; (ii) the histological distribution varies according to the anatomo-functional classification; and (iii) different dermoscopic patterns are able to discriminate malignant from benign aMPPLs within specific plantar and palmar areas.

Comparison of Melanocyte-Associated Immunohistochemical Markers in Acral Lentiginous Melanoma and Acral Benign Nevi

ABSTRACT

Acral lentiginous melanoma (ALM) is a relatively rare clinicopathologic subtype of cutaneous malignant melanoma, but it is the most common type of melanoma among Asians. Although the research to identify immunohistochemical (IHC) markers to differentiate nevi from melanoma is being conducted, specific markers for ALM are not well-known. Therefore, we aimed to analyze and compare the differences in the expression of melanocyte-associated IHC markers between ALM and acral benign nevi (ABN). Two independent groups of 53 and 19 paraffin-embedded specimens (from patients with pathologically confirmed ALM and ABN, respectively) were subjected to IHC staining for MART-1, preferentially expressed antigen in melanoma (PRAME), SOX10, HMB-45, Ki-67, and p16. We performed a quantitative analysis of PRAME, SOX10, KI-67, and p16 expression and gradient pattern analysis of HMB-45 expression for each specimen. The PRAME (60.1% and 28.5%, P < 0.05) and Ki-67 (7.8% and 3.5%, P < 0.05) expression levels were significantly higher in the ALM group than in the ABN group. The p16 expression was significantly lower (14.2% and 19.4%, P < 0.05), and the absence of HMB-45 gradient was more frequent in the ALM group than in the ABN group. However, no statistical significance was noted in SOX10 (54.8% and 44.7%). Receiver operating characteristic curves showed that PRAME had the highest area under the curve value. In summary, among various IHC markers, PRAME was the most valuable marker for the diagnosis of ALM; however, further large-scale studies are needed to validate these findings.

Diagnosis and Management of Acral Pigmented Lesions

BACKGROUND

Survival outcomes in acral lentiginous melanoma (ALM) are worse than for cutaneous melanoma. Diagnostic delays are believed to contribute to worse outcomes in ALM, including advanced-stage disease at initial presentation. Acral lentiginous melanoma, especially in its early stages, may be difficult to discern from benign pigmented acral lesions.

OBJECTIVE

The purpose of this article is to provide a comprehensive review of the diagnosis and management of acral pigmented lesions.

MATERIALS AND METHODS

A literature review was performed. The outcomes included were the clinical and dermoscopic features and the management frameworks and considerations for acquired and congenital melanocytic nevi, acral melanosis, nonmelanocytic pigmented lesions, and ALM.

RESULTS

Original research studies were primarily included. The use of dermoscopy, such as the 3-step algorithm and blotch (irregular), ridge pattern (parallel), asymmetry of structures, asymmetry of colors, furrow pattern (parallel), fibrillar pattern (BRAAFF) checklist, increases the diagnostic accuracy of acral pigmented lesions with high specificity and sensitivity. Short-term digital dermoscopic surveillance can be used to manage acral lesions, and histopathology should be collected when there is a concern for ALM.

CONCLUSION

The use of dermoscopy and an understanding of how to manage acral lesions may limit the number of biopsies performed on the acral skin, decrease the time to diagnosis, and facilitate early detection of ALM.

Dermoscopy of melanoma according to different body sites: Head and neck, trunk, limbs, nail, mucosal and acral

Effective cancer screening detects early-stage tumours, leading to a lower incidence of late-stage disease over time. Dermoscopy is the gold standard for skin cancer diagnosis as diagnostic accuracy is improved compared to naked eye examinations. As melanoma dermoscopic features are often body site specific, awareness of common features according to their location is imperative for improved melanoma diagnostic accuracy. Several criteria have been identified according to the anatomical location of the melanoma. This review provides a comprehensive and contemporary review of dermoscopic melanoma criteria according to specific body sites, including frequently observed melanoma of the head/neck, trunk and limbs and special site melanomas, located on the nail, mucosal and acral region.

Melanoma in skin of color: Part I. Epidemiology and clinical presentation

Although there is a higher incidence of melanoma among non-Hispanic White individuals, melanoma is diagnosed at more advanced stages and associated with worse survival rates among individuals with skin of color (SOC). The proportions of melanoma subtypes differ across racial groups, with acral lentiginous melanoma and mucosal melanoma representing higher proportions of melanoma diagnoses in individuals with SOC compared to White individuals. The recognition of distinct differences in anatomic locations and dermatoscopic patterns may facilitate the appropriate differentiation of physiologic from pathologic pigmentation. The first article of this continuing medical education series will focus on the epidemiology and clinical presentation of melanoma in individuals with SOC, with the aim of improving early diagnoses and clinical outcomes.

European consensus-based interdisciplinary guideline for melanoma. Part 1: Diagnostics: Update 2022

Cutaneous melanoma (CM) is potentially the most dangerous form of skin tumor and causes 90% of skin cancer mortality. A unique collaboration of multi-disciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organization for Research and Treatment of Cancer (EORTC) was formed to make recommendations on CM diagnosis and treatment, based on systematic literature reviews and the experts' experience. The diagnosis of melanoma can be made clinically and shall always be confirmed with dermatoscopy. If a melanoma is suspected, a histopathological examination is always required. Sequential digital dermatoscopy and full body photography can be used in high-risk patients to improve the detection of early melanoma. Where available, confocal reflectance microscopy can also improve clinical diagnosis in special cases. Melanoma shall be classified according to the 8th version of the American Joint Committee on Cancer classification. Thin melanomas up to 0.8 mm tumor thickness do not require further imaging diagnostics. From stage IB onwards, examinations with lymph node sonography are recommended, but no further imaging examinations. From stage IIC onwards whole-body examinations with computed tomography (CT) or positron emission tomography CT (PET-CT) in combination with brain magnetic resonance imaging are recommended. From stage III and higher, mutation testing is recommended, particularly for BRAF V600 mutation. It is important to provide a structured follow-up to detect relapses and secondary primary melanomas as early as possible. There is no evidence to define the frequency and extent of examinations. A stage-based follow-up scheme is proposed which, according to the experience of the guideline group, covers the optimal requirements, but further studies may be considered. This guideline is valid until the end of 2024.

Frequency of Publication of Dermoscopic Images in Inter-observer Studies: A Systematic Review

Research interest in dermoscopy is increasing, but the complete dermoscopic image sets used in inter-observer studies of skin tumours are not often shared in research publications. The aim of this systematic review was to analyse what proportion of images depicting skin tumours are published in studies investigating inter-observer variations in the assessment of dermoscopic features and/or patterns. Embase, MEDLINE and Scopus databases were screened for eligible studies published from inception to 2 July 2020. For included studies the proportion of lesion images presented in the papers and/or supplements was extracted. A total of 61 studies (53 original studies and 8 shorter reports (i.e. research letters or concise reports)). published in the period 1997 to 2020 were included. These studies combined included 14,124 skin tumours, of which 373 (3%) images were published. This systematic review highlights that the vast majority of images included in dermoscopy research are not published. Data sharing should be a requirement for future studies, and must be enabled and standardized by the dermatology research community and editorial offices.

Review article: Emerging issues in pediatric skin of color, Part 2

Dermatology for pediatric skin of color is the application of dermatology to the genetically diverse and distinctive segment of the pediatric population that includes children of non-White racial and ethnic groups with increased pigmentation including individuals of Asian, Hispanic/LatinX, African, Native American, Pacific Island descent, indigenous people among others with overlap in particular individuals, and mixtures thereof. The discipline of pediatric skin of color can be challenging with difficulty in diagnosis of common conditions due to underlying pigmentation, variations in common hair styling practices, and differences in demographics of cutaneous disease. Whereas some conditions are more common in children of color, other conditions have nuances in clinical appearance and therapeutics with regard to skin color. This article, the second of the series, focuses on inflammatory skin disease nuances, melanocytic disorders, and hypopigmented mycosis fungoides.

More than just acral melanoma: the controversies of defining the disease

Acral melanoma (AM) is a malignant cutaneous melanocytic tumour specifically located on the palms, soles, and nail apparatus, which are areas of glabrous (hairless) skin. Acral lentiginous melanoma, a subtype of AM, represents a histopathological subtype diagnosis of cutaneous melanoma with unique morphological and structural features. Despite clear definitions, the misuse of these terms and the inconsistency in reporting the histopathological features of AM cases have become a major obstacle to the study of the disease. In this review, we discuss the epidemiology, histopathological features, prognosis, and genetic profile of AM, highlighting the differences observed when histopathological subtypes are considered. The increasing global effort to characterise AM cases from ethnically diverse populations would benefit greatly from a more consistent classification of the disease.

Evolution of the Clinical, Dermoscopic and Pathologic Diagnosis of Melanoma

The conventional narrative states that the steadily rising incidence of melanoma among fair-skinned Caucasian populations during the last decades is caused by excessive UV-exposure. There is, however, no doubt that other factors had a significant impact on the rising incidence of melanoma. Pre-1980s the clinical diagnosis of melanoma was based on gross criteria such as ulceration or bleeding. Melanomas were often diagnosed in advanced stages when the prognosis was grim. In the mid-1980s education campaigns such as the propagation of the ABCD criteria, which addressed health care professionals and the public alike, shifted the focus towards early recognition. Dermatoscopy, which became increasingly popular in the mid-1990s, improved the accuracy for the diagnosis of melanoma in comparison to inspection with the unaided eye, especially for flat and small lesions lacking ABCD criteria. At the same time, pathologists began to lower their thresholds, particularly for the diagnosis of melanoma in situ. The melanoma epidemic that followed was mainly driven by an increase in the number of in situ or microinvasive melanomas. In a few decades, the landscape shifted from an undercalling to an overcalling of melanomas, a development that is now met with increased criticism. The gold standard of melanoma diagnosis is still conventional pathology, which is faced with low to moderate interobserver agreement. New insights in the molecular landscape of melanoma did not translate into techniques for the reliable diagnosis of gray zone lesions including small lesions. The aim of this review is to put our current view of melanoma diagnosis in historical context and to provide a narrative synthesis of its evolution. Based on this narrative I will provide suggestions on how to rebuild the trust in melanoma diagnosis accuracy and in the benefit of early recognition.

Histopathologic classification and prognostic factors of melanoma: a 2021 update

Despite the rapid recent advances in molecular analysis of tumors, which allow large-scale and high-resolution genomics, the "gold standard" for melanoma diagnosis continues to be histopathology, in conjunction with clinical characteristics and sometimes with important support of immunohistochemistry. Observations, where postulated that cutaneous melanomas may arise through two distinct pathways, discoveries such as that BRAF^V600E mutations were mostly common in melanomas on sun-exposed skin with little solar elastosis and seminal works for melanoma progression and evolution set the groundwork for the new WHO Classification of Melanoma: a classification of melanoma that not only encompasses histologic but also clinical, epidemiologic, and genetic characteristics. The melanomas were divided into those etiologically related to sun exposure and those that are not, based on their mutational signatures, anatomic site, and epidemiology. On the basis of degree of associated solar elastosis melanomas on the sun exposed skin were further divided by the histopathologic degree of cumulative solar damage (CSD) of the surrounding skin, into low and high CSD. On the low-CSD group of melanomas are included superficial spreading melanomas, while the high-CSD melanomas encompasses lentigo maligna and desmoplastic melanomas. The "non-CSD" classification includes acral melanomas, some melanomas in congenital nevi, melanomas in blue nevi, Spitz melanomas, mucosal melanomas, and uveal melanomas. Nodular and nevoid melanoma may occur in any pathway. A group of intermediate tumors termed melanocytoma is proposed for tumors that in addition to mutations that activate the MAPK pathway, harbor multiple driver mutations, and they are either low-grade or high-grade, to indicate that they may carry a higher risk of malignant transformation. In this review a summary of the most recent WHO classification of melanoma is provided. A short analysis of essential histopathologic prognostic parameters is also provided. The new classification of melanoma discriminates distinct types of melanoma based on their clinicopathologic, and genomic characteristics. Undoubtedly, melanoma research will continue to evolve as new clinical, pathological, molecular data accumulates. The challenge of the forthcoming years is to better characterize the intermediate category of melanocytic lesions.

Dermoscopic features of neoplasms in skin of color: A review

BACKGROUND

Dermoscopy is undoubtedly a useful tool to improve diagnostic accuracy and minimize the number of unnecessary biopsies. However, much of the literature on dermoscopy focuses on findings in lighter-skin phototypes, leaving potential gaps of knowledge regarding its use in skin of color (SoC). As the clinical applications of dermoscopy continue to increase, understanding dermoscopic patterns in SoC is imperative.

OBJECTIVE

This review discusses the literature on dermoscopic findings of neoplasms in SoC, highlighting unique and characteristic dermoscopic features.

METHODS

A literature review was performed using the PubMed database. Case reports, case series, case-control studies, and systematic reviews were included.

RESULTS

A total of 8326 studies were identified based on the selected search terms, and 41 were included in this review based on relevance.

CONCLUSION

There are specific dermoscopic characteristics in SoC for benign nevi, acral lentiginous melanoma, ethnic melanonychia, and dermatofibroma; however, there is a lack of published data about specific features of cutaneous melanoma, subungual melanoma, pigmented basal cell carcinoma, and pigmented squamous cell carcinoma in SoC. Because pigmented basal cell carcinoma, pigmented squamous cell carcinoma, ethnic melanonychia, and acral lentiginous melanoma are diagnosed at later stages in this population, it is important to understand their dermoscopic features. Further descriptive studies are needed to better characterize unique dermoscopic features in neoplasms in SoC.

Acral lentiginous melanoma: Basic facts, biological characteristics and research perspectives of an understudied disease

Acral lentiginous melanoma is a histological subtype of cutaneous melanoma that occurs in the glabrous skin of the palms, soles and the nail unit. Although in some countries, particularly in Latin America, Africa and Asia, it represents the most frequently diagnosed subtype of the disease, it only represents a small proportion of melanoma cases in European-descent populations, which is partially why it has not been studied to the same extent as other forms of melanoma. As a result, its unique genomic drivers remain comparatively poorly explored, as well as its causes, with current evidence supporting a UV-independent path to tumorigenesis. In this review, we discuss current knowledge of the aetiology and diagnostic criteria of acral lentiginous melanoma, as well as its epidemiological and histopathological characteristics. We also describe what is known about the genomic landscape of this disease and review the available biological models to explore potential therapeutic targets.

Acral lentiginous melanoma in situ: dermoscopic features and management strategy

Diagnosis of acral lentiginous melanoma in situ (ALMIS) is challenging. However, data regarding ALMIS are limited in the literature. The aim of this study was to investigate the clinical and dermoscopic features of ALMIS on palmoplantar surfaces. Patients with ALMIS and available dermoscopic images were retrospectively reviewed at our institution between January 2013 and February 2020. Clinical and dermoscopic features were analysed and compared between small (< 15 mm) and large (≥ 15 mm) ALMIS. Twenty-one patients with ALMIS were included in this study. Mean patient age was 58.5 (range 39-76) years; most lesions were located on the sole (90.5%). The mean maximal diameter was 19.9 ± 13.7 mm (mean ± standard deviation). Statistical analysis of dermoscopic features revealed that parallel ridge patterns (54.5% vs. 100%, P = 0.035), irregular diffuse pigmentation (27.3% vs. 100%, P = 0.001) and grey colour (18.2% vs. 90%, P = 0.002) were significantly less frequent in small lesions than in large lesions. We have also illustrated two unique cases of small ALMIS; their evolution and follow-up dermoscopic examination are provided. In conclusion, this study described detailed dermoscopic findings of ALMIS. Based on the present study and a review of the literature, we proposed a dermoscopic algorithm for the diagnosis of ALMIS.

Clinical and Histopathologic Characteristics of Melanocytic Lesions on the Volar Skin Without Typical Dermoscopic Patterns

Importance

It is challenging to differentiate melanoma from melanocytic nevus on the volar skin in the absence of typical dermoscopic patterns.

Objective

To identify the frequency and clinical and dermoscopic characteristics of melanocytic lesions on the volar skin not displaying a parallel furrow pattern, lattice-like pattern, fibrillar pattern, or parallel ridge pattern on results of dermoscopy.

Design, Setting, and Participants

In this retrospective cohort study, a total of 504 melanocytic lesions on the volar skin were evaluated in the Shinshu University Hospital department of dermatology between January 1, 2000, and December 31, 2012. Dermoscopic images were independently assessed by 3 dermoscopists for the presence of established dermoscopic criteria. Statistical analysis was performed from October 1, 2017, to April 30, 2018.

Main Outcomes and Measures

Frequency of dermoscopic criteria and corresponding clinical (patient age and size and location of lesion) and histopathologic features.

Results

Of 504 lesions, 110 (21.8%) (melanocytic nevus, 97; melanoma, 8; and equivocal melanocytic lesion, 5) from 108 patients (68 female and 40 male patients; mean age, 40.1 years [range, 1-86 years]) did not show a parallel furrow pattern, lattice-like pattern, fibrillar pattern, or parallel ridge pattern. Among them, the mean patient age was significantly higher for melanoma than for melanocytic nevus (65.3 vs 38.0 years; P < .001), as was mean maximum lesion diameter (11.8 vs 5.7 mm; P < .001). Melanomas and equivocal melanocytic lesions tended to be distributed on weight-bearing areas of the foot sole, such as the heel, while nevi were spread over non-weight-bearing regions. Dermoscopically, 95 melanocytic nevi (97.9%) were symmetrical in 1 or 2 axes while melanomas were not. A total of 91 melanocytic nevi (93.8%) had 1 or 2 colors per lesion, and 4 melanomas (50.0%) had more than 2 colors. Vascular structures were seen in 3 melanocytic nevi (3.1%) and 3 melanomas (37.5%). Blue-white structures were seen in 18 melanocytic nevi (18.6%) and 3 melanomas (37.5%). Dots and globules were seen in 22 melanocytic nevi (22.7%) and 4 melanomas (50.0%). Vascular structures, blue-white structures, and dots and globules were irregularly distributed in the melanomas. Ulcer, hyperkeratosis, and irregular streaks were observed only in melanomas.

Conclusions and Relevance

More than one-fifth of melanocytic lesions on the volar skin did not display typical dermoscopic patterns. Asymmetry, numerous colors (≥3), and other melanoma-specific dermoscopic findings were more frequently observed for melanomas. Clinical information, including patient age and lesion size and location, was helpful in differentiating melanoma from melanocytic nevus. Further prospective clinical studies are warranted to clarify the diagnostic accuracy of dermoscopy combined with clinical information.

Dermoscopy of Melanoma and Non-melanoma Skin Cancers

Dermoscopy is a widely used non-invasive technique for diagnosing skin tumors. In melanocytic tumors, e.g., melanoma and basal cell carcinoma (BCC), the effectiveness of dermoscopic examination has been fully established over the past two decades. Moreover, dermoscopy has been used to diagnose non-melanocytic tumors. Here, we review novel findings from recent reports concerning dermoscopy of melanoma and non-melanoma skin cancers including BCC, sebaceous carcinoma, actinic keratosis, Bowen's disease, squamous cell carcinoma (SCC), Merkel cell carcinoma (MCC), extramammary Paget's disease (EMPD), and angiosarcoma.

Clinical, Epidemiological, and Molecular Heterogeneity in Acral Melanoma

Acral melanoma comprises a poorly characterized and distinct type of melanoma, in terms of differing roles of UVR, molecular substrate, distribution among all ethnicities, and poor prognosis. Haugh et al. explore clinical, histological, and molecular aspects of acral melanomas and provide insights into the complexity of these tumors.

Early detection of acral melanoma: A review of clinical, dermoscopic, histopathologic, and molecular characteristics

Acral lentiginous melanoma is a distinct subtype of melanoma on acral skin. Patient presentation at later stages and delayed diagnosis by physicians contribute to a worse associated prognosis and survival rate. Despite our progress in understanding the key features of this disease, the diagnosis of early-stage acral melanoma is still challenging. It is essential to integrate clinical, dermoscopic, and histologic findings in the diagnosis of acral lentiginous melanoma. In addition, molecular studies can be helpful. In this review, we have summarized our current understanding of this disease entity from articles that were published between 1969 and 2018. We have outlined clinical and dermoscopic features as well as pathologic and molecular findings regarding acral melanoma and have presented an algorithm for diagnosis. Understanding and integrating these characteristics may assist clinicians in the early detection of acral melanomas.

Visual inspection and dermoscopy, alone or in combination, for diagnosing keratinocyte skin cancers in adults

BACKGROUND

Early accurate detection of all skin cancer types is important to guide appropriate management, to reduce morbidity and to improve survival. Basal cell carcinoma (BCC) is almost always a localised skin cancer with potential to infiltrate and damage surrounding tissue, whereas a minority of cutaneous squamous cell carcinomas (cSCCs) and invasive melanomas are higher-risk skin cancers with the potential to metastasise and cause death. Dermoscopy has become an important tool to assist specialist clinicians in the diagnosis of melanoma, and is increasingly used in primary-care settings. Dermoscopy is a precision-built handheld illuminated magnifier that allows more detailed examination of the skin down to the level of the superficial dermis. Establishing the value of dermoscopy over and above visual inspection for the diagnosis of BCC or cSCC in primary- and secondary-care settings is critical to understanding its potential contribution to appropriate skin cancer triage, including referral of higher-risk cancers to secondary care, the identification of low-risk skin cancers that might be treated in primary care and to provide reassurance to those with benign skin lesions who can be safely discharged.

OBJECTIVES

To determine the diagnostic accuracy of visual inspection and dermoscopy, alone or in combination, for the detection of (a) BCC and (b) cSCC, in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in person) or based on remote (image-based) assessment.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies of any design that evaluated visual inspection or dermoscopy or both in adults with lesions suspicious for skin cancer, compared with a reference standard of either histological confirmation or clinical follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic thresholds were missing. We estimated accuracy using hierarchical summary ROC methods. We undertook analysis of studies allowing direct comparison between tests. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely-developed algorithm to assist diagnosis; and observer expertise.

MAIN RESULTS

We included 24 publications reporting on 24 study cohorts, providing 27 visual inspection datasets (8805 lesions; 2579 malignancies) and 33 dermoscopy datasets (6855 lesions; 1444 malignancies). The risk of bias was mainly low for the index test (for dermoscopy evaluations) and reference standard domains, particularly for in-person evaluations, and high or unclear for participant selection, application of the index test for visual inspection and for participant flow and timing. We scored concerns about the applicability of study findings as of 'high' or 'unclear' concern for almost all studies across all domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The detection of BCC was reported in 28 datasets; 15 on an in-person basis and 13 image-based. Analysis of studies by prior testing of participants and according to observer expertise was not possible due to lack of data. Studies were primarily conducted in participants referred for specialist assessment of lesions with available histological classification. We found no clear differences in accuracy between dermoscopy studies undertaken in person and those which evaluated images. The lack of effect observed may be due to other sources of heterogeneity, including variations in the types of skin lesion studied, in dermatoscopes used, or in the use of algorithms and varying thresholds for deciding on a positive test result.Meta-analysis found in-person evaluations of dermoscopy (7 evaluations; 4683 lesions and 363 BCCs) to be more accurate than visual inspection alone for the detection of BCC (8 evaluations; 7017 lesions and 1586 BCCs), with a relative diagnostic odds ratio (RDOR) of 8.2 (95% confidence interval (CI) 3.5 to 19.3; P < 0.001). This corresponds to predicted differences in sensitivity of 14% (93% versus 79%) at a fixed specificity of 80% and predicted differences in specificity of 22% (99% versus 77%) at a fixed sensitivity of 80%. We observed very similar results for the image-based evaluations.When applied to a hypothetical population of 1000 lesions, of which 170 are BCC (based on median BCC prevalence across studies), an increased sensitivity of 14% from dermoscopy would lead to 24 fewer BCCs missed, assuming 166 false positive results from both tests. A 22% increase in specificity from dermoscopy with sensitivity fixed at 80% would result in 183 fewer unnecessary excisions, assuming 34 BCCs missed for both tests. There was not enough evidence to assess the use of algorithms or structured checklists for either visual inspection or dermoscopy.Insufficient data were available to draw conclusions on the accuracy of either test for the detection of cSCCs.

AUTHORS' CONCLUSIONS

Dermoscopy may be a valuable tool for the diagnosis of BCC as an adjunct to visual inspection of a suspicious skin lesion following a thorough history-taking including assessment of risk factors for keratinocyte cancer. The evidence primarily comes from secondary-care (referred) populations and populations with pigmented lesions or mixed lesion types. There is no clear evidence supporting the use of currently-available formal algorithms to assist dermoscopy diagnosis.

Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults

BACKGROUND

Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Although history-taking and visual inspection of a suspicious lesion by a clinician are usually the first in a series of 'tests' to diagnose skin cancer, dermoscopy has become an important tool to assist diagnosis by specialist clinicians and is increasingly used in primary care settings. Dermoscopy is a magnification technique using visible light that allows more detailed examination of the skin compared to examination by the naked eye alone. Establishing the additive value of dermoscopy over and above visual inspection alone across a range of observers and settings is critical to understanding its contribution for the diagnosis of melanoma and to future understanding of the potential role of the growing number of other high-resolution image analysis techniques.

OBJECTIVES

To determine the diagnostic accuracy of dermoscopy alone, or when added to visual inspection of a skin lesion, for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in-person), or based on remote (image-based), assessment.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies of any design that evaluated dermoscopy in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. Data on the accuracy of visual inspection, to allow comparisons of tests, was included only if reported in the included studies of dermoscopy.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated accuracy using hierarchical summary receiver operating characteristic (SROC),methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; observer expertise; and dermoscopy training.

MAIN RESULTS

We included a total of 104 study publications reporting on 103 study cohorts with 42,788 lesions (including 5700 cases), providing 354 datasets for dermoscopy. The risk of bias was mainly low for the index test and reference standard domains and mainly high or unclear for participant selection and participant flow. Concerns regarding the applicability of study findings were largely scored as 'high' concern in three of four domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The accuracy of dermoscopy for the detection of invasive melanoma or atypical intraepidermal melanocytic variants was reported in 86 datasets; 26 for evaluations conducted in person (dermoscopy added to visual inspection), and 60 for image-based evaluations (diagnosis based on interpretation of dermoscopic images). Analyses of studies by prior testing revealed no obvious effect on accuracy; analyses were hampered by the lack of studies in primary care, lack of relevant information and the restricted inclusion of lesions selected for biopsy or excision. Accuracy was higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio (RDOR) 4.6, 95% confidence interval (CI) 2.4 to 9.0; P < 0.001).We compared accuracy for (a), in-person evaluations of dermoscopy (26 evaluations; 23,169 lesions and 1664 melanomas),versus visual inspection alone (13 evaluations; 6740 lesions and 459 melanomas), and for (b), image-based evaluations of dermoscopy (60 evaluations; 13,475 lesions and 2851 melanomas),versus image-based visual inspection (11 evaluations; 1740 lesions and 305 melanomas). For both comparisons, meta-analysis found dermoscopy to be more accurate than visual inspection alone, with RDORs of (a), 4.7 (95% CI 3.0 to 7.5; P < 0.001), and (b), 5.6 (95% CI 3.7 to 8.5; P < 0.001). For a), the predicted difference in sensitivity at a fixed specificity of 80% was 16% (95% CI 8% to 23%; 92% for dermoscopy + visual inspection versus 76% for visual inspection), and predicted difference in specificity at a fixed sensitivity of 80% was 20% (95% CI 7% to 33%; 95% for dermoscopy + visual inspection versus 75% for visual inspection). For b) the predicted differences in sensitivity was 34% (95% CI 24% to 46%; 81% for dermoscopy versus 47% for visual inspection), at a fixed specificity of 80%, and predicted difference in specificity was 40% (95% CI 27% to 57%; 82% for dermoscopy versus 42% for visual inspection), at a fixed sensitivity of 80%.Using the median prevalence of disease in each set of studies ((a), 12% for in-person and (b), 24% for image-based), for a hypothetical population of 1000 lesions, an increase in sensitivity of (a), 16% (in-person), and (b), 34% (image-based), from using dermoscopy at a fixed specificity of 80% equates to a reduction in the number of melanomas missed of (a), 19 and (b), 81 with (a), 176 and (b), 152 false positive results. An increase in specificity of (a), 20% (in-person), and (b), 40% (image-based), at a fixed sensitivity of 80% equates to a reduction in the number of unnecessary excisions from using dermoscopy of (a), 176 and (b), 304 with (a), 24 and (b), 48 melanomas missed.The use of a named or published algorithm to assist dermoscopy interpretation (as opposed to no reported algorithm or reported use of pattern analysis), had no significant impact on accuracy either for in-person (RDOR 1.4, 95% CI 0.34 to 5.6; P = 0.17), or image-based (RDOR 1.4, 95% CI 0.60 to 3.3; P = 0.22), evaluations. This result was supported by subgroup analysis according to algorithm used. We observed higher accuracy for observers reported as having high experience and for those classed as 'expert consultants' in comparison to those considered to have less experience in dermoscopy, particularly for image-based evaluations. Evidence for the effect of dermoscopy training on test accuracy was very limited but suggested associated improvements in sensitivity.

AUTHORS' CONCLUSIONS

Despite the observed limitations in the evidence base, dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants, particularly in referred populations and in the hands of experienced users. Data to support its use in primary care are limited, however, it may assist in triaging suspicious lesions for urgent referral when employed by suitably trained clinicians. Formal algorithms may be of most use for dermoscopy training purposes and for less expert observers, however reliable data comparing approaches using dermoscopy in person are lacking.

Dermatoscopy of Neoplastic Skin Lesions: Recent Advances, Updates, and Revisions

OPINION STATEMENT

Dermatoscopy (dermoscopy) improves the diagnosis of benign and malignant cutaneous neoplasms in comparison with examination with the unaided eye and should be used routinely for all pigmented and non-pigmented cutaneous neoplasms. It is especially useful for the early stage of melanoma when melanoma-specific criteria are invisible to the unaided eye. Preselection by the unaided eye is therefore not recommended. The increased availability of polarized dermatoscopes, and the extended use of dermatoscopy in non-pigmented lesions led to the discovery of new criteria, and we recommend that lesions should be examined with polarized and non-polarized dermatoscopy. The "chaos and clues algorithm" is a good starting point for beginners because it is easy to use, accurate, and it works for all types of pigmented lesions not only for those melanocytic. Physicians, who use dermatoscopy routinely, should be aware of new clues for acral melanomas, nail matrix melanomas, melanoma in situ, and nodular melanoma. Dermatoscopy should also be used to distinguish between different subtypes of basal cell carcinoma and to discriminate highly from poorly differentiated squamous cell carcinomas to optimize therapy and management of non-melanoma skin cancer. One of the most exciting areas of research is the use of dermatoscopic images for machine learning and automated diagnosis. Convolutional neural networks trained with dermatoscopic images are able to diagnose pigmented lesions with the same accuracy as human experts. We humans should not be afraid of this new and exciting development because it will most likely lead to a peaceful and fruitful coexistence of human experts and decision support systems.