EVIDENCE-BASED DERMATOLOGY: ORIGINAL CONTRIBUTION

Is Dermoscopy (Epiluminescence Microscopy)

Useful for the Diagnosis of Melanoma?
Results of a Meta-analysis Using Techniques Adapted
to the Evaluation of Diagnostic Tests
Marie-Lise Bafounta, MD; Alain Beauchet, MD, PhD; Philippe Aegerter, MD, PhD; Philippe Saiag, MD

Objective: To assess, by means of meta-analysis tech-
niques for diagnostic tests, the accuracy of dermoscopic
(also known as dermatoscopy and epiluminescence mi-
croscopy) diagnosis of melanoma performed by experi-
enced observers vs naked-eye clinical examination.
Data Sources: MEDLINE, EMBASE, PASCAL-BIOMED,
and BIUM databases were screened through May 31, 2000,
without any language restrictions.
Study Selection: Original studies were selected when
the following criteria were met: spectrum of lesions well
described, histologic findings as standard criterion, and
calculated or calculable sensitivity and specificity. Eight
of 672 retrieved references were retained.
Data Synthesis: Selected studies represented 328 mela-
nomas, mostly less than 0.76 mm thick, and 1865 mostly
melanocytic benign pigmented skin lesions. For dermo-
scopic diagnosis of melanoma, the sensitivity and speci-
ficity ranges were 0.75 to 0.96 and 0.79 to 0.98, respec-
tively. Dermoscopy had significantly higher discriminating
power than clinical examination, with respective esti-
mated odds ratios of 76 (95% confidence interval, 25-
223) and 16 (95% confidence interval, 9-31) (P=.008),
and respective estimated positive likelihood ratios of 9
(95% confidence interval, 5.6-19.0) and 3.7 (95% con-
fidence interval, 2.8-5.3). The roles of the number of le-
sions analyzed, the percentage of melanoma lesions, the
instrument used, and dermoscopic criteria used in each
study could not be proved.

Data Extraction: Three investigators extracted data. In
case of disagreement, consensus was obtained. Sum-
mary receiver operating characteristic curve analysis was
used to describe the central tendency of the studies, and
to compare dermoscopy and clinical examination.
Conclusion: For experienced users, dermoscopy is more
accurate than clinical examination for the diagnosis of
melanoma in a pigmented skin lesion.
Arch Dermatol. 2001;137:1343-1350

From the Service de
Dermatologie
(Drs Bafounta and Saiag) and
Antenne d’Informatique
Médicale (Drs Beauchet and
Aegerter), Hôpital Ambroise
Paré, Assistance
Publique-Hôpitaux de Paris,
Boulogne, France.
M
ORBIDITY and mortal-
ity attributed to skin
melanoma have dra-
matically increased in
recent years.1 As there
is a strong inverse correlation between sur-
vival rate and tumor thickness, and no ef-
fective therapy exists for advanced mela-
noma, early diagnosis and excision are
essential to reduce morbidity and im-
prove patients’ survival. Dermoscopy (also
known as dermatoscopy, epilumines-
cence microscopy, incident light micros-
copy, and skin-surface microscopy) is a
noninvasive technique to examine pig-
mented anatomic structures of the epider-
mis, dermoepidermal junction, and su-
perficial papillary dermis that are not
visible to the naked eye.2 The technique
uses in vivo microscopy with fluid ap-
plied to the skin to render the stratum cor-
neum more translucent. Various instru-
ments have been used, ranging from widely
used, inexpensive, handheld instru-
ments (eg, Dermatoscope [Heine Ltd,
Herrshing, Germany] and Episcope
[Welch Allyn Inc, Skaneateles Falls, NY])
that provide a fixed magnification of ⫻10,
to binocular microscopes and, more re-
cently, to digital videomicroscopy,3 the
last 2 options providing higher magnifi-
cation.
For editorial comment
see page 1361
It has been claimed that dermos-
copy improves sensitivity (up to 30%) and
specificity of melanoma diagnosis com-
pared with clinical diagnosis4-11 and thus
could lower the excision rate of histologi-
cally benign but clinically doubtful nevi.
However, there is no consensus on this

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 METHODS
We followed the guidelines for meta-analyses evaluating
diagnostic tests.15,18
DATA SOURCES
Four bibliographic databases were screened through May
31, 2000: (1) the online MEDLINE (National Library of
Medicine, Bethesda, Md; http://www.ncbi.nlm.nih.gov/
entrez/query.fcgi) from January 1968; (2) Elsevier Sci-
ence online EMBASE (http://www.ovid.com/products/
databases/database_info.cfm) from 1989; (3)
PASCAL-BIOMED on CD-ROM (http://www.silverplatter
.com/catalog/pbma.htm), which also contains congres-
sional reports, from 1987; and (4) BIUM (Bibliothèque In-
ter Universitaire Médicale, Paris, France), which contains
all French doctoral theses in medicine from 1985.
No language restrictions were applied. The MEDLINE
search was conducted by successively calling the follow-
ing keywords: dermatoscopy, dermoscopy, epilumines-
cence microscopy, diascopy, surface microscopy, incident
light microscopy, in combination with melanoma or
skin neoplasm (exploded mode), sensitivity, and specific-
ity. Similar strategies were used to search EMBASE and
PASCAL-BIOMED. Other sources were the references of
the retrieved articles and textbooks on the topic. All of the
retrieved references were entered into the bibliography man-
agement software EndNote 3.01 (ISI Research Soft, Berke-
ley, Calif), to facilitate the search for duplicate references.
STUDY SELECTION
Three investigators, 2 dermatologists (M.-L.B. and P.S.) and
1 statistician (A.B.), independently reviewed the studies and
filled in preestablished evaluation grids. In case of divergent
evaluations, consensus was obtained. We first selected origi-
nal studies on dermoscopy by reading the titles and ab-
stracts. An initial review evaluated selected studies for the fol-
lowing quality criteria: spectrum of included patients well
claim,12 and studies on dermoscopy to detect malignant
melanoma are heterogeneous in their design and the types
of dermoscopic criteria for melanoma applied.13 It has also
been reported that dermoscopy does not sufficiently
improve the accuracy of diagnosis to alter the clinical
management of most pigmented skin lesions (PSLs).13
To objectively assess the diagnostic accuracy of der-
moscopy in detecting melanoma, we performed a meta-
analysis. This method is the critical review of the litera-
ture and mathematical combination of the results of
previous research, to obtain a quantified and reproduc-
ible synthesis of data, and to diminish the bias of each
study.14 While it is mostly used to assess studies on thera-
peutic efficacy, this method can also evaluate diagnostic
tests.15,16 Such meta-analyses can (1) provide an overall
summary of diagnostic accuracy; (2) determine whether
estimates of diagnostic accuracy depend on the study de-
sign characteristics (study validity) of primary studies;
(3) determine whether diagnostic accuracy differs in sub-
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described (with a spectrum of melanoma lesions and lesions
commonly confused with melanoma), blinded comparison
of diagnostic tests with histologic findings as the standard cri-
terion, and calculated or calculable statistical values (sensi-
tivity, specificity, and positive and negative likelihood
ratios).18,19 A study was held to be of insufficient quality when
1 criterion was absent. Studies of acceptable quality were fi-
nally selected when the diagnostic performance of dermos-
copy on melanoma was compared with that of naked-eye clini-
cal examination and when dermoscopy was performed by
experienced operators. Excluded from this research were re-
views; editorials; original articles on the development of der-
moscopic criteria for diagnosing PSLs, terminology of der-
moscopy, accuracy of diagnosis of a single type of PSL, and
accuracy of computer-assisted lesion analysis; and studies not
comparing dermoscopy with naked-eye examination.
DATA EXTRACTION
The following data were extracted from selected articles (af-
ter translation if not in English or French): setting, lesion-
selection criteria, total number and spectrum of lesions ana-
lyzed, prevalence of melanoma, Breslow index of the tested
melanomas, degree of observer blinding, study type (pro-
spective study or analysis of randomly selected lesions from
a database), instrument used, criteria applied for clinical and
dermoscopic diagnoses, dermoscopy reproducibility, and per-
centage of lesions in which no dermoscopic diagnosis could
be made. The potential bias of these studies was ana-
lyzed.15,18 Dermoscopic criteria for melanoma were classi-
fied as either pattern analysis20 (even when slightly differ-
ent pattern criteria were added to the original publication)
or ABCD21 (asymmetry, border, color, and differential struc-
ture) or 7FFM22 (7 features for melanoma) criteria. Sensi-
tivity, specificity, and positive and negative likelihood ra-
tios were calculated according to standard formulas. When
possible, these values were recalculated from the data given
in the articles. When dermoscopy was performed by both
nonexpert and expert observers, we selected only the re-
sults recorded by skilled operators. When individual clini-
cal or dermoscopic evaluations from multiple observers were
groups defined by the characteristics of the patients and
tests; and (4) identify areas for future research. To as-
sess the clinical value of dermoscopy in the evaluation
of PSL, we focused our analysis on the comparison of der-
moscopic and naked-eye clinical examinations. As train-
ing in dermoscopy clearly improves diagnostic efficacy,
we restricted our analysis to dermoscopy performed by
formally trained operators.17
RESULTS
LITERATURE SEARCH
Five hundred sixty-four articles were identified from
MEDLINE, 223 from EMBASE (with 138 references found
in both databases), 117 from PASCAL-BIOMED (with 96
references also found in MEDLINE or EMBASE), and 2
doctoral theses from the BIUM database. After elimina-
WWW.ARCHDERMATOL.COM
 given in a study, we retained only the responses most fre-
quently given by the investigators. When melanoma had
been clinically diagnosed according to the ABCDE (asym-
metry, border, color, diameter, and evolution) criteria, we
required the presence of at least 2 criteria; this gives the
best sensitivity with acceptable specificity.23
STATISTICS
Sensitivity and specificity, commonly used in diagnostic
tests, rely on a single threshold whose modification to in-
crease sensitivity decreases specificity, and vice versa. When
studies use different criteria to define positive and nega-
tive test results, the thresholds differ. Even when studies
apply the same criteria, the thresholds may not be the same,
since interpretation of the test depends on subjective judg-
ment. To take different thresholds into account across stud-
ies, we used summary receiver operating characteristic
(sROC) curve analysis, proposed by Moses et al,24 to de-
scribe the central tendency of the studies, and also to com-
pare the discriminatory powers of naked-eye clinical ex-
amination and dermoscopy. The significance of differences
was statistically analyzed by applying a Wilcoxon paired-
sample test to the parameter Ln(odds ratio), where Ln in-
dicates the neperian logarithm. A P value less than .05 was
considered significant. Estimated positive and negative like-
lihood ratios were calculated from the point of intersec-
tion of the sROC curve with the line (1−specificity)+ sen-
sitivity=1, which slopes from the upper left to the lower
right corners.24 At that intersection, sensitivity equals speci-
ficity. That point is a global measurement of test efficacy.
Statistical analysis was performed with the SAS 6.12 soft-
ware package (SAS Institute Inc, Cary, NC).
CONSTRUCTION OF sROC CURVES
A diagnostic test within a single study may have several com-
binations of sensitivity and specificity values, depending
on the threshold value. The graph reporting these values
(where the y-axis represents true-positive rate values [TPR,
sensitivity] and the x-axis represents false-positive rate
tion of duplicates, we obtained 672 studies. Screening of
the reference lists of retrieved articles and textbooks dis-
closed no additional studies.
STUDY SELECTION
Forty-nine studies were subjected to further selection pro-
cedures after we read their titles and abstracts. Thirty-
four references fulfilled the required quality criteria. Eight
studies, all referenced in the MEDLINE database, met all
of our selection criteria.7-12,22,25
The study by Stanganelli et al25 was included de-
spite the absence of histologic findings for 92% of the 3372
PSLs assessed, for the following reasons: (1) all lesions
clinically or dermoscopically suspected of being mela-
noma had been subjected to histologic examination, thus
allowing the calculation of true- and false-positive evalu-
ations, and (2) all of the included patients were inhab-
itants of the region covered by the Romagna Cancer Reg-
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values [FPR, 1−specificity]) defines the receiver operating
characteristic (ROC) space, and the points within this space
are the combinations of the different values. The ROC curve
joins the different points and enables assessment of the varia-
tion of sensitivity as a function of varying specificity. The
closer the curve comes to the upper left-hand corner of the
graph, the better the test.
While the ROC curve illustrates data for a diagnostic
test coming from a single study, an sROC curve fits data
from different studies into the same curve. The method used
in this study, proposed by Moses et al,24 follows these steps:
1. Convert each FPR and TPR into its logistic trans-
formation (logit):
U=logit(FPR)=Ln[FPR/(1−FPR)]
V=logit(TPR)=Ln[TPR/(1−TPR)]
2. For each study, calculate:
D=V−U=Ln(odds ratio),
where the odds ratio equals [TPR/(1−TPR)]/[FPR/(1−FPR)]
and D measures how well the test discriminates between sub-
jects with and without the disease.
S=V+U,
where S is a measurement of the threshold for classifying
a test as positive.
3. Plot each study’s point (Si,Di) in an (S,D) space and
fit an unweighted least-squares regression line. The linear
regression model is:
D=␣+␤S.
The regression coefficient ␤ provides an estimate of the ex-
tent to which the Ln(odds ratio) is dependent on the thresh-
old used. If it is near 0, the common odds ratio is given by
exp␣.
4. Reverse-transform (TPR) and plot the sROC curve
onto the FPR-vs-TPR graph.
TPR={1+exp-␣/(1-␤) [(1−FPR)/FPR](1+␤)/(1-␤)}-1
5. Compare the 2 diagnostic tests. All the points are
plotted for both tests in the (S,D) space, and the regres-
sion line is fitted. If ␤ is nonstatistically different from 0, a
Wilcoxon paired-samples test is applied to compare the Ln
(odds ratio) for clinical examination and dermoscopy.
istry, and the entire series of patients with benign clinical
or dermoscopic diagnosis and no referral for excision were
cross-checked with this registry a median of 31 months
after dermoscopic examination. This registry has good
indicators of satisfactory levels of registration complete-
ness,25 and we ascertained that it contains the expected
number of patients with melanoma,26 as compared with
the most recent figures of disease incidence in Italy.27 Only
2 additional patients with melanoma have been found.
Thus, only a few patients with melanoma seem to have
been missed in that study. As our standard criterion was
histologic findings, only verified lesions were consid-
ered for the analyses presented in Table 1 (see below),
including those found through the cancer registry.
The exclusion of certain studies needs further ex-
planation. In one article, the standard criterion did not
allow clear discrimination between melanoma and atypi-
cal nevus.28 Although Ascierto et al29 tested 15719 PSLs,
the results of clinical and dermoscopic examinations were
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 Table 1. Design of the Selected Studies*

Method of Clinical Method of Dermoscopic

Lesion Selection Diagnosis of Dermoscopy Criteria for
Source Setting/Study Type Criteria Observers Melanoma (Magnification) Melanoma
Benelli et al22 Dermatologic surgery All consecutive PSLs 2 Dermatologists, ABCDE Not given 7FFM (score ⱖ2)
department/ excised during 1 y not involved in (ⱖ2 criteria)
prospective in vivo (No. of patients decision whether
evaluation not given) to excise lesions
Carli et al11 Dermatology Not given 15 Dermatologists, Not given Dermaphot† (slides Pattern analysis
department/ all skilled taken at ⫻10
retrospective magnification)
evaluation of
photographs
Cristofolini et al10 Dermatology All consecutive PSLs 4 Dermatologists, ABCDE criteria Handheld Pattern analysis
department/ excised during 9 with consensus (ⱖ2 criteria) dermoscope (⫻10)
prospective in vivo mo (700 patients evaluation
evaluation during a seen), all nevi with
campaign for the ABCDE criteria ⱖ1
early detection of excised
melanoma
Dummer et al9 Dermatology All consecutive 3 Dermatologists, ABCDE criteria Videomicroscopy Pattern analysis
department/ difficult-to- not involved in (threshold not (⫻25 to ⫻400)
prospective in vivo diagnose PSLs decision whether given)
evaluation seen during 1 y to excise lesions,
(No. of patients not involved in
not given) clinical diagnosis
Krähn et al8 Dermatology Not given Not given Not given Not given Not given
department/
prospective in vivo
evaluation
Lorentzen et al7 Dermatology All clinical and 4 Expert Not given Dermaphot (slides Pattern analysis
department/ dermatoscopic dermatologists taken at ⫻10)
retrospective photographs of (5 novices
evaluation on PSLs taken during discarded)
photographs a 4-y period
Soyer et al12 PSL clinic/prospective Not given, but 3 Expert Not given Handheld Pattern analysis
in vivo evaluation among clinically dermatologists dermoscope
difficult-to- (⫻10) and
diagnose PSLs stereomicroscope
referred by (⫻6 to ⫻40)
general
practitioners or
dermatologists
Stanganelli et al25 Skin cancer All patients with 1 Expert ABCDE (threshold Stereomicroscope Pattern analysis,
clinic/prospective PSLs recorded in dermatologist not given) (⫻ 6 to ⫻16) and with digital
in vivo evaluation database (see digital contrast and
“Results” section) videomicroscopy enhancement
(⫻6 to ⫻40) procedures

*PSL indicates pigmented skin lesion. ABCDE are clinical criteria for the diagnosis of melanoma23; 7FFM, dermoscopic criteria for the diagnosis of melanoma.22
†Heine Ltd, Herrshing, Germany.

not clearly reported. The possibility of performing “in-
formal” dermoscopy to support the clinical evaluation,
as explained by Nachbar et al,5 could have biased the clini-
cal diagnosis. In both studies, the choice of lesions to be
assessed by the standard criterion (ie, histologic find-
ings) was also dictated by the result of dermoscopy (veri-
fication bias). The well-done study by Steiner et al6 was
eliminated because of the unavailability of data to cal-
culate dichotomous outcomes of melanoma or nonmela-
noma for dermoscopy, although such data were given for
the clinical evaluations. Two studies17,30 were excluded
because dermoscopy was compared with pictures taken
without oil at magnifications of ⫻16 and ⫻10, respec-
tively, and not with naked-eye examination. The study
by Pazzini et al31 was rejected because the data needed
to calculate sensitivity, specificity, and likelihood ratios
were not reported, although figures were given for diag-
nostic accuracy and index of suspicion.
INTERNAL AND EXTERNAL VALIDITY
OF THE SELECTED STUDIES
The main characteristics of the 8 retained studies are given
in Table 1. All came from dermatology departments, were
published between 1993 and 2000, and were set in der-
matology clinics or even in specialized PSL clinics. Two
studies were performed on images originating from a da-
tabase, and 6 prospectively recorded dermoscopy re-
sults in vivo. As required by our selection criteria, all stud-
ies used histologic findings as a standard criterion, but
only 4 had histologic findings verified by an external re-
view or derived from a consensus among at least 2 ob-

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 servers.7-9,25 Although clearly stated only for the 2 stud-
ies with image databases, clinical and dermoscopic
examinations seem to have been conducted in all stud-
ies independent of the standard criterion because of evi-
dent temporal relationship. The choice of patients to be
assessed by the standard criterion was not entirely inde-
pendent of the test results, as, in all studies, lesions were
excised mainly because of a clinically presumed risk of
malignancy or, possibly, patient request. Only Stangan-
elli et al25 collected information aimed at calculating the
true false-negative rate (see above). Lesion-selection cri-
teria were absent or almost absent from 2 articles. It was
stated in only 4 reports that all consecutive PSLs ex-
cised4,9 or recorded7,25 within a determined period had
been included.
To assess the validity of the comparison between
clinical and dermoscopic evaluations, we investigated
their independence. Only 111 of the 2 retrospective
studies clearly stated that the dermoscopic evaluations
had been made without knowing the results of the
clinical ones, and both claimed that dermoscopy did
not influence clinical judgment.7,11 For the 6 in vivo
dermoscopic evaluations, it is highly probable that der-
moscopy had been performed after the lesions were
examined with the naked eye. Clinical evaluations were
clearly recorded before dermoscopy was done in all but
2 of these studies.12,25
Criteria for the clinical diagnosis of melanoma were
specified in 4 reports, with a threshold value clearly given
in only 2. The number of clinically atypical nevi was not
clearly stated in most studies. The instruments used dif-
fered among the studies. Transparencies taken with a Der-
maphot (Heine Ltd) at original ⫻10 magnification were
analyzed in 2 studies.7,11 One study used a handheld mon-
ocular dermoscope with ⫻10 magnification,10 and an-
other used a digital videomicroscope with magnifica-
tions up to ⫻400.9 One study used both a handheld
dermoscope (⫻10) and a binocular stereomicroscope (⫻6
to ⫻40),12 and another one, both a stereomicroscope (⫻6
to ⫻16) and digital videomicroscopy (⫻6 to ⫻40)25 with
digital contrast and enhancement procedures, but none
clearly distinguished their results. One study indepen-
dently assessed dermoscopy (with an unspecified instru-
ment) and high-frequency sonography.8 No authors stated
that a skin lesion could not be diagnosed by dermos-
copy, and only one group7 stated that 4% of the photo-
graphs were not suitable for evaluation. Various dermo-
scopic criteria have been used to diagnose melanoma:
pattern analysis for 6 studies and 7FFM criteria for 1
study.4 Interobserver agreement for dermoscopy was as-
sessed simultaneously in only 1 study.11
The spectrum of lesions examined is given in
Table 2. There were 2193 lesions, with 328 melano-
mas. Sample size varied from 15 to 824 lesions. Mela-
noma lesions represented 3% to 49% of the excised le-
sions. Most melanomas were thin (⬍0.76 mm) in the 4
studies that provided such information. Nonmelanoma
lesions represented 1865 lesions. Their histologic find-
ings were detailed in all but 1 study25; they were mainly
melanocytic lesions (67%-100% of all nonmelanoma
PSLs). No study gave demographic information on in-
cluded patients.
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RESULTS OF SELECTED STUDIES
Results of the 8 studies are summarized in Table 2. The
respective sensitivity, specificity, and positive and nega-
tive likelihood ratio ranges were as follows: 0.50 to 0.94,
0.55 to 0.89, 1.91 to 10.66, and 0.61 to 0.08 for the clini-
cal diagnosis of melanoma; and 0.75 to 0.96, 0.79 to
0.98, 4.21 to 76.62, and 0.28 to 0.04 for the dermoscopic
diagnosis of melanoma. Variations of sensitivity, specific-
ity, and positive and negative likelihood ratios for the di-
agnoses of melanoma after dermoscopy were as follows:
−0.05 to +0.30, 0.00 to +0.33, 0.00 to +65.96, and −0.34 to
0.00, respectively.
According to the results of 5 studies, dermoscopy had
higher sensitivity than nondermoscopic diagnosis,7-9,11,25
but only 2 of them demonstrated statistical signifi-
cance.7,25 Because individual data were not detailed in the
3 remaining reports, we were unable to perform post hoc
statistical tests. In the only study that addressed that is-
sue, the improvement of sensitivity was more pro-
nounced for melanomas less than 0.76 mm thick, as com-
pared with thicker ones.25 In all of these studies, specificity
and positive and negative likelihood ratios were also bet-
ter. Four of these studies used high-magnification der-
moscopy, with either Dermaphot or videomicroscopy. The
remaining one provided no information on the instru-
ment used.
For 2 studies, in which the clinical evaluation al-
ready had achieved high sensitivity and specificity, no
difference was found between clinical and dermoscopic
assessments.10,12 For another study, in which the clini-
cal evaluation had high sensitivity but low specificity, der-
moscopy had comparable sensitivity but better specific-
ity and positive and negative likelihood ratios.22
STATISTICS
The sROC curves of clinical and dermoscopic evalua-
tions of melanoma (Figure) indicate that dermoscopy
has significantly higher discriminatory power, with es-
timated odds ratios of 76 (95% confidence interval [CI],
25-223) vs 16 (95% CI, 9-31) for naked-eye examina-
tion (P =.008). The weighted least squares, the robust-
resistant line, and other methods proposed by Moses et
al24 gave similar values. For dermoscopy and naked-eye
examination, respectively, the estimated positive likeli-
hood ratios were 9 (95% CI, 5.6-19.0) and 3.7 (95% CI,
2.8-5.3), and the estimated negative likelihood ratios, 0.11
(95% CI, 0.05-0.18) and 0.27 (95% CI, 0.19-0.36). Ex-
ploratory analyses were performed to investigate whether
diagnostic accuracy differed in subgroups defined by the
characteristics of the patients and diagnostic tests. No re-
lationship could be established between dermoscopic di-
agnostic sensitivity and the number of lesions analyzed,
the percentage of melanoma lesions, or the dermoscope
or dermoscopic criteria used.
COMMENT
Our results showed that, for dermatologists working
within specialized clinics and experienced in dermos-
copy, this technique has higher discriminatory power than
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 Table 2. Main Results of the Selected Studies

No. of No. of
No. of Melanomas Nonmelanoma Sensitivity Specificity
No. of Melanomas ⬍0.76-mm Thick Lesions
Source Lesions (% of Lesions) (% of Melanomas) (% Melanocytic) Clinical Dermoscopy Clinical Dermoscopy
Benelli et al22 401 60 (15) 48 (80) 341 (99) 0.85 0.80* 0.55 0.89†
Carli et al11 15 4 (27) Not given 11 (100) 0.50 0.75‡ 0.82 0.91‡
Cristofolini et al10 220 33 (15) Not given 187 (97) 0.85 0.88* 0.75 0.79*
Dummer et al9 824 23 (3) Not given 801 (89) 0.65 0.96‡ 0.93 0.98‡
Krähn et al8 80 39 (49) 29 (74) 41 (100) 0.79 0.90‡ 0.78 0.93‡
Lorentzen et al7 232 49 (21) Not given 183 (78) 0.78 0.82§ 0.89 0.94§
Soyer et al12 159 65 (41) 38 (58) 94 (67) 0.94 0.94* 0.82 0.82*
Stanganelli et al25 262 55 (21) 24 (46) 207 (Not given) 0.67 0.93§ 0.84 0.94§

*Not significant (P ⱖ.05).

†P⬍.01.
‡Not done.
§P⬍.05.

1.0 mate of diagnostic accuracy of a test among primary studies

12-12 Dermoscopy
4 26
Clinical Examination
is not simply the calculation of the mean sensitivity and
0.9 10
8
9
25 10
25
the mean specificity of this test. Such an approach would
0.8 8 9
be inappropriate, because it is likely that different studies
11
0.7 4 26 used different explicit or implicit thresholds, so that a pri-
0.6 mary study with high sensitivity may have low specific-
Sensitivity

11
0.5
0.4
0.3
0.2
0.1
0.0
0.0 0.1 0.2 0.3 0.4 0.5 0.6
1–Specificity
Summary receiver operating characteristic curves showing the
discriminatory powers of both naked-eye examination (triangles,
discontinuous curve) and dermoscopy (circles, continuous curve) for
melanoma diagnosis. The closer the curve comes to the upper left-hand
corner of the graph, the better the test. The curves suggest the superiority
of dermoscopy over naked-eye examination. Numbers next to triangles or
circles correspond to the reference citations of the studies analyzed. See
“Methods” section for details.
does naked-eye examination to detect melanoma in a PSL.
As other studies have shown that dermoscopy increased
the diagnostic ability only when performed by formally
trained operators,17,32,33 dermatologists should make ev-
ery efforts to master this useful tool.
These conclusions are more favorable for dermos-
copy than those of Mayer’s systematic review.13 One ex-
planation is that she selected only 2 studies on this is-
sue, whereas we retained 5 additional studies published
later and another study published in German.
Moreover, we were able to obtain a quantitative sum-
mary of the diagnostic efficacy of dermoscopy by apply-
ing meta-analysis methods adapted for the evaluation of
diagnostic tests.15,16,18,24 To the best of our knowledge, we
have used this approach for the first time in dermatology,
as a MEDLINE search (data not shown) did not find any
meta-analysis for diagnosis of skin diseases. Indeed, meta-
analyses are more commonly conducted to examine treat-
ments or prognosis. In fact, obtaining a summary esti-
ity, and vice versa. That is why it is recommended, for each
primary study, to plot a scattergram of the true-positive
rate (sensitivity) against the false-positive rate (1−speci-
ficity), which are also the axes used for an sROC curve.15
The odds ratio of each primary study can be combined,
allowing the 95% CI to be calculated and statistical com-
parisons between different diagnostic tests to be made. Fur-
0.7 0.8 0.9 1.0
thermore, it is possible to calculate estimated positive and
negative likelihood ratios for dermoscopy for the detec-
tion of melanoma, which are more useful for clinicians than
odds ratios. As dermoscopy achieved likelihood ratios far
from 1, this technique seemed an accurate diagnostic test.
It should be noted that values greater than 10 or less than
0.1 are considered to generate large and often conclusive
changes from pretest to posttest probability, and values
of 5 to 10 and 0.1 to 0.2, moderate but substantial shifts
of these probabilities.34 Thus, this technique gives pre-
cise information on the confidence clinicians may have in
a test to detect or exclude a disease, ie, with dermoscopy
of a PSL to exclude melanoma and to decide not to excise
a clinically doubtful lesion. However, this technique is com-
plex, particularly when subgroup analysis or modeling is
done. Therefore, someone with methodologic expertise
should be included in the research team,18 as in our study.
As for all meta-analyses, one important limitation is
publication bias, with small studies on dermoscopy or with
negative results not having been submitted or accepted for
publication. We tried to limit this handicap by conduct-
ing a comprehensive search in 4 different databases, in-
cluding 2 databases potentially covering studies unpub-
lished in the peer-reviewed medical literature. This strategy
proved useful, because overlaps between these databases
were small. The selection of relevant studies followed
strictly established guidelines,15,18 with extensive evalua-
tion of the design and validity of selected studies. How-
ever, because we retained only studies that met predeter-
mined quality criteria, numerous others were rejected.

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Positive Likelihood Ratio Negative Likelihood Ratio
Clinical Dermoscopy Clinical Dermoscopy
1.91 7.18 0.27 0.23
2.75 8.25 0.61 0.28
3.45 4.21 0.20 0.15
10.66 76.62 0.37 0.04
3.62 7.18 0.26 0.23
7.10 13.58 0.25 0.20
5.19 5.19 0.08 0.08
4.22 16.00 0.39 0.08
This approach explains, at least partially, why we were
unable to explore with adequate statistical power an-
other objective of such a meta-analysis, the effect of vari-
ability of study design (eg, instrument or dermoscopic di-
agnostic criteria used, percentage of melanomas among the
lesions, types of nonmelanoma lesions, total number of
lesions examined, or setting) on accuracy estimates. In-
deed, before attempting to extrapolate our findings, it must
be recalled that the diagnostic efficacy of the handheld,
low-magnification, inexpensive dermoscope was not shown
to be significantly superior to clinical examination in the
only study to test that instrument.10 All other studies in-
vestigated instruments with higher magnification rates,
such as stereomicroscope, videomicroscope, or the less ex-
pensive Dermaphot, which dramatically increases the mag-
nification of the lesion by the projection on a screen, but
is not suitable to give immediate information. Concern-
ing the dermoscopic criteria for melanoma used, only one
study22 used structured explicit criteria such as 7FFM35
or ABCD,21 which have been reported to have increased
sensitivity and specificity for detecting melanoma.5,36 Most
studies examined a distorted spectrum of PSLs, with far
too many melanoma and too few nonmelanocytic PSLs,
such as seborrheic keratoses, as compared with their fre-
quency in usual dermatology consultant practices. As der-
moscopy is a subjective interpretation of images, a high
number of melanomas in the sample may modify the
threshold of the observer to conclude that melanoma is
present. Finally, as all selected studies were conducted in
clinics with expertise on PSLs, the place of dermoscopy
in general dermatology practice remains unknown.
Some limitations of the selected studies are, never-
theless, obvious. First, although pathologists may vary in
classifying PSLs,37 only a few studies commented on how
the standard criterion was reached. Second, in some se-
lected studies, naked-eye examination and dermoscopy
were not performed totally independently, and dermos-
copy could have “improved” the accuracy of the clinical
diagnosis proposed. Third, the impact of the verification
bias (mainly clinically equivocal lesions were excised) pre-
sent in most studies must be considered. Although Stan-
ganelli et al25 gave reassuring indirect information on that
issue, such studies may overestimate the sensitivity of der-
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moscopy by missing some false-negative cases. Notably,
the clinical threshold for considering a lesion sufficiently
suspect to be excised seemed to have been set low (at least
2 ABCDE criteria) in the 2 studies that gave this informa-
tion. Fourth, data concerning intraobserver and interob-
server variability were absent or sparse in most selected
studies. However, satisfactory reproducibility of the der-
moscopy results was shown in most studies specifically
addressing that issue.11,17,22
Nevertheless, several points enhance the value of der-
moscopy in detecting melanoma. First, its superiority to
clinical examination was demonstrated despite the high
sensitivity and specificity of the clinical diagnosis of mela-
noma reported in most selected studies, as compared with
figures usually published.38 This finding may be ex-
plained by the expertise in PSLs of most investigators,
rather than by the high percentage of melanomas among
the lesions examined. Second, mostly highly equivocal
(ie, mainly or exclusively melanocytic) benign lesions and
thin, early melanomas, presumably difficult to diagnose
but highly curable by complete excision, were exam-
ined. In this situation, sensitivity and specificity of the
technique are expected to decrease. However, although
dermoscopy seems to have all the qualities required for
a good diagnostic test—accuracy, absence of adverse effect,
target disorder dangerous if left undiagnosed, and effec-
tive treatment of the disease when diagnosed early34—
its usefulness, which means providing information be-
yond that otherwise available and inciting a change of
patient treatment, remains to be proved.
To provide better evidence of the usefulness of der-
moscopy, future research should address the following
issues. Studies should be undertaken to analyze, in the
standard dermatology practice, a more representative mix-
ture of melanoma and benign PSLs, as well as studies
aimed to lower the number of unknown false-negative
results. The value of the handheld low-magnification der-
matoscope needs to be assessed. However, the most im-
portant issue would be to prove in a large patient popu-
lation that, with dermoscopy, it is possible to reduce the
number of excision biopsies performed for nonmela-
noma PSLs while increasing the number of thin mela-
nomas excised or, at least, without increasing the num-
ber of melanomas missed.
Accepted for publication April 30, 2001.
The authors received no outside support for this study.
We thank Janet Jacobson for editing our English and
Marie-Dominique Allen for her help in searching comput-
erized databases.
Corresponding author: Philippe Saiag, MD, Service de
Dermatologie, Hôpital Ambroise Paré, 9, av Charles-de-
Gaulle, 92104 Boulogne CEDEX, France (e-mail:
dermato.dermato@apr.ap-hop-paris.fr).
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