Introduction to dermoscopy for

medical students and incoming

dermatology residents

Department of Dermatology
University of North Carolina at Chapel Hill
David M. Wang, MD, Nikita Goel, MD, Mark Ash, MD, Julie Mervak, MD
Acknowledgements
We thank the faculty and resident physicians at our program for their
commitment to dermoscopy education and for contributing to the
database of dermoscopy images from which we drew these examples.
Outline
• Introduction

• Technique

• Benign diagnoses

• Pre-malignant and malignant diagnoses

• Infectious diagnoses
Introduction
Introduction
• Synonyms: dermatoscopy, epiluminescence microscopy, skin
surface microscopy, magnified oil immersion diascopy

• Dermoscopy is an in vivo, noninvasive technique that can reveal

morphologic features that cannot be seen with the naked eye,
thereby enhancing diagnostic accuracy.

• Dermoscopy is used to aid in the decision-making process of

whether to perform a biopsy or refer to dermatology.
Advantages and limitations of dermoscopy
Advantages Limitations
Correlation of clinical exam with dermoscopy findings aids in Anchoring bias (the tendency to more heavily favor initial
differential diagnosis and proper identification of tumoral information)
pathologies

Allows for digital surveillance and monitoring of melanocytic Search satisfaction (once a diagnosis is reached, there may be
lesions a tendency to neglect other important findings which could
impact the clinical diagnosis)

Improves the diagnostic accuracy, sensitivity, and specificity Clinician dependent diagnostic accuracy to correctly identify
for diagnosing melanoma relevant structures

Reduces the number of unnecessary biopsies Limited ability to detect very early and featureless melanomas

Quick, non-invasive tool Cannot rely on dermoscopy alone - must consider clinical
context
Colors in dermoscopy

From Marghoob AA, Malvehy J, Braun RP. Atlas of

Dermoscopy. 2nd ed. London: Informa Healthcare; 2012.
Benign melanocytic nevi patterns

From Marghoob AA, Malvehy J, Braun RP. Atlas of Dermoscopy. 2nd ed. London: Informa
Healthcare; 2012.
Melanoma specific structures

From Marghoob AA, Malvehy J, Braun RP. Atlas of Dermoscopy. 2nd ed. London: Informa
Healthcare; 2012.
Vascular patterns in
dermoscopy

From Martín JM, Bella-Navarro R,

Jordá E. Vascular patterns in
dermoscopy. Actas Dermosifiliogr.
2012 Jun;103(5):357-75.
 General algorithm
Skin lesion

Melanocytic Non-melanocytic
Lorem Ipsum

Malignant or pre-
Lorem
Benign
Ipsum Lorem
Malignant
Ipsum Lorem
Benign
Ipsum Lorem Ipsum
malignant

Atypical pigment network

Negative pigment network
Diffuse reticular Streaks Milia-like cysts Leaf-like structures
Patchy reticular Off-center blotch Comedo-like openings Spoke wheel / concentric structures
Peripheral reticular with central hyper- or Atypical dots or globules Fingerprint-like structures Blue-gray ovoid nests
hypopigmentation Regression Gyri and sulci Blue-gray globules or dots
Homogenous Blue-white veil Red lacunae Glomerular vessels
Peripheral globules / starburst Atypical vasculature Crown vessels Arborizing vessels
Peripheral reticular with central globules Crystalline structures Dotted vessels in serpiginous distribution Strawberry pattern
Globular Peripheral brown structureless areas Red homogenous areas intersected by whitish Multiple blood crusts over a red
Two components Milky red areas lines background
Comma-shaped vessels Polymorphous vessels
Corkscrew vessels
Linear irregular vessels
Technique
Technique
Three types of dermoscopy techniques:
1) Polarized without contact
• Allows for visualization of blood vessels
2) Polarized with contact
From Marghoob AA, Malvehy J, Braun RP.
• Allows for visualization of the deeper layers of the Atlas of Dermoscopy. 2nd ed. London: Inform
Healthcare; 2012.
epidermis and papillary dermis
• Better sensitivity for detection of skin cancer
3) Nonpolarized with contact
• Requires a liquid interface (ultrasound gel or alcohol gel) to be placed
between the skin and the glass plate of the dermatoscope
• Allows for visualization of the superficial epidermis
• Better specificity for detection of benign lesions
Technique
Step 1: Clean surface with alcohol wipe
• Tip: Fluid also eliminates surface light reflection and renders stratum
corneum transparent, which allows for visualization of subsurface colors and
structures.

Step 2: Start with polarized non-contact mode

Step 3: Proceed with polarized contact mode

Step 4: Toggle to non-polarized contact mode

• Tip: Gently press the dermatoscope against the skin with the liquid interface
in between.

Step 5: Clean dermatoscope with alcohol wipe

Benign diagnoses
Benign diagnoses
• Benign nevus
• Junctional nevus
• Compound nevus
• Intradermal nevus
• Seborrheic keratosis
• Lentigo
• Lichen planus-like keratosis
• Cherry hemangioma
• Sebaceous hyperplasia
• Dermatofibroma
• Acral nevus
• Blue nevus
• Talon noir
• Subungual hemorrhage
Junctional nevus
• Junctional nevi clinically appear as
symmetrical, monomorphic, brown
macules or papules.
• Dermoscopy demonstrates a
reticular pattern
reticular network pattern of
pigmentation.
Compound nevus
• Compound nevi present with
homogenous pigmentation or
brown, black, or blue-greyish papillomatous
appearance
globules.

brown
globules
 Intradermal nevus
• Intradermal nevi (IDN) will have
comma vessels which are slightly
curved and barely branched.
• Compared to the arborizing vessels in
basal cell carcinomas (BCCs) which are
larger and more in focus. Vessels
are always best viewed with polarized
non-contact mode.

• Positive "wobble sign" which is

helpful to delineate between IDN
comma vessels
and BCCs. IDNs will roll back and
forth and not just move with the
contact with the dermatoscope.
 Seborrheic keratosis
• Dermoscopy features of seborrheic keratoses (SKs)
include fissures and ridges (cerebriform pattern),
comedo-like openings, milia-like cysts (seen on non-
polarized settings--look like "stars in the sky"), and
hairpin vessels with surrounding white halo. cerebriform
pattern

comedo-like
openings

milia-like
cysts
comedo-like
openings
Lentigo
moth-eaten
border
• Lentigines will often demonstrate a moth-eaten symmetric
follicular
border (sharp demarcation and irregular curved pigmentation
border, scalloped), homogenous light brown
color, and symmetric follicular pigmentation
which are all seen in our example.
• Lentigines can also sometimes show a pigment
network (this becomes more confusing with
melanoma), fingerprint-like areas (fine parallel
lines of light and dark brown colors that look like
dermatoglyphics), and a pseudonetwork (diffuse
homogenous
pigment interrupted by adnexal openings). light brown
color
Lichen planus-like keratosis
• Lichen planus-like keratosis will
show diffuse granular pattern
(peppering of brown, grey,
bluish-grey granules) scattered
homogeneously throughout
the lesion or just localized granular
pattern
granular pattern.
• Look for changes of the original
lesion (SK vs lentigo) in the
remainder. This will give you a
clue that the granules
represent regression.
 Sebaceous hyperplasia
• Sebaceous hyperplasia
crown vessels
demonstrates white-yellow
lobular structures and
overlying vessels. The
vessels extend toward
but do not cross the center
of the lesion (unlike white-yellow
lobular structures
arborizing vessels of BCCs)
so these are referred to as
"crown vessels." Crown
vessels are specific to
sebaceous hyperplasia.
 Dermatofibroma peripheral
pigment network

• There are several patterns for

dermoscopy of dermatofibromas.
Commonly there is homogenous
pigmentation, a peripheral pigment
network, and a central white
central white
network. White streaks can also be network
seen.

white
streaks
 Acral nevus
• Acral nevi can have several patterns,
including parallel furrow, lattice-like,
and fibrillar patterns.
• Lesions that demonstrate parallel
ridge pattern or asymmetry of color
and structure are concerning for
melanoma. parallel furrow lattice-like
pattern pattern
• The example on the left
demonstrates the parallel furrow ink test
pattern. The ink test demonstrates
that the ink settles in the furrows and
you can see that's where the pigment
is most prominent in this nevus.
• The example on the right
demonstrates a lattice-like pattern
with pigmentation following the
furrows plus linear bands of pigment
crossing from one furrow to the next
like rungs on a ladder.
 Blue nevus
• Blue nevi have homogenous
structureless steel blue
pigmentation, sometimes with a
faded border or white areas
corresponding to fibrosis. homogenous
steel blue
pigmentation

homogenous faded border

structureless
pigmentation
Talon noir (subcorneal hemorrhage)
• Before and after photos for removal involves
of the subcorneal hemorrhage ridges and
furrows
(talon noir) with a No. 15 blade.
• The top photo shows smooth
sharp margins, involvement of both
ridges and furrows, and a reddish-
brown color. There is no true sharp margins
pigment network.

removed by
paring
Subungual hemorrhage
• Subungual hemorrhage usually
appears reddish-brown to reddish-
red-black
black on dermoscopy with red-black globules
globules along the edges. The distal
part may show streaks. Overall the
color is homogenous (no gray
granules like with melanocytic
lesions).
• This should grow out with the nail. If it
doesn't grow out with the nail it is
important to consider a nail bed tumor
causing continued bleeding.
Pre-malignant and malignant
diagnoses
Pre-malignant diagnoses
• Actinic keratosis

Malignant diagnoses
• Basal cell carcinoma
• Squamous cell carcinoma
• Melanoma
Actinic keratosis
• Nonpigmented actinic keratoses (AKs) on the red-pink
head and neck show the “strawberry pattern”-- pseudonetwork

background erythema sparing the follicles

creating a red-pink pseudonetwork, whitish-
yellow scale, fine wavy vessels around the hair
follicles, and follicular openings surrounded by
a white halo and filled with a keratotic plug.
• On polarized mode you can see the "rosette
sign" in AKs. This is a white four-leaf clover
shaped pattern in the follicle for the polarized
light reflecting against the
orthokeratosis/parakeratosis.
whitish
scale
Actinic keratosis (pigmented)
• Sometimes pigmented AKs can be
very hard to tell from lentigo
maligna (LM) because they can have
pigmented follicular
similar features. openings
• Pigmented AKs are seen more often
in patients with slightly darker skin
(like Fitzpatrick type 3). Both
pigmented AKs and LM can have
pigmented follicular openings,
annular-granular pattern, and
rhomboidal structures. Only LM will
have pigment that fills the follicular
openings but usually this is later
stage and could be invasive lentigo
maligna melanoma (LMM).
Basal cell carcinoma
• Superficial BCCs demonstrate short fine
superficial telangiectasias, shiny white-red
structureless areas, and multiple small
erosions.
• Nodular or infiltrative BCCs demonstrate
arborizing vessels (which can cross the midline),
chrysalis structures (white streaks that
represent fibrosis in the dermis) or ulceration. arborizing
vessels
• Pigmented BCCs can demonstrate large blue-
gray ovoid nests, maple-leaf-like areas, erosions
spokewheel-like areas, and in-focus dots.

maple leaf-
like areas
blue-gray
ovoid nests
Squamous cell carcinoma in situ
glomerular
vessels
• Dermoscopy in squamous cell
carcinoma in situ shows surface
scale and numerous glomerular
(coiled) vessels arranged in focal
clusters. keratin-filled
• There can also be keratin-filled ostia ostia
(white circles with central yellow
keratin plug) and surrounding
superficial
dotted vessels. scale
 Squamous cell carcinoma
• Squamous cell carcinoma (SCC) can
present with surface scale and white
circles centered around dilated
infundibulum filled with a keratin
plug (yellow or orange color). serpentine
• The vessel patterns at the periphery vessels

of an SCC can be variable, but are keratin plugs

often hairpin, linear, serpentine,
or dotted vessels. surface scale
 Lentigo maligna angulated lines,
rhomboidal structures

• LM has asymmetric pigmentation of the

follicular openings, peripheral streaking,
annular granular pattern (dots around
adnexal structures), angulated lines or
gray rhomboidal structures, and the
asymmetric
isobar sign (circle within a circle). follicular pigmentation
• The bottom left image demonstrates
features of regression, including isobar sign
peppering of blue-gray fine dots and
scar-like depigmentation.
• Tip: LMM (no longer in situ) may have
pigment covering the follicles.

regression features
 Melanoma regression
areas

• The examples on this slide are of

superficial spreading melanomas.
• Features of melanoma include radial peripheral black
dots/globules
streaming, multiple colors, blue-
blue-white
white veil, peripheral black veil
dots/globules, negative pigment
network, peripheral light brown radial
streaming
structureless areas, crystalline
structures, and atypical vessels or
crystalline structures
milky-red color.
• With superficial spreading
melanomas, you can see atypical
broadened network and blue-gray
dots (“peppering” seen in
regression).
tan structureless areas
Melanoma (continued)
negative
pigment
• The examples on this slide are of network
nodular melanomas.
• Some features of superficial
spreading melanomas such as
atypical broadened network and blue-white
blue-gray dots "peppering" are not veil

typically seen in nodular

melanomas.

crystalline
structures
Subungual melanoma Hutchinson
sign

• Predictive features of subungual

melanoma on dermoscopy
include:
• Width of pigment at least 3 mm
(even more suspect if >6 mm)
• Asymmetry
• Border fading
• Multiple colors (dark brown and gray
being most common)
• Positive Hutchinson sign (periungual
extension of brown/black pigment
from melanonychia onto the
proximal or lateral nailfold)
multiple colors
Cutaneous metastatic melanoma
homogenous
• Dermoscopy demonstrates blue-black color
homogenous blue-black color, some
with a peripheral reddish-brown
halo.
peripheral
halo
Infectious diagnoses
Infectious diagnoses
• Wart
• Molluscum contagiosum
• Scabies
• Herpes zoster
• Tinea capitis
• Tinea nigra
Wart
finger-like projections of
filiform wart

• Common warts (verruca vulgaris)

appear as keratinocytic papules with
a lobular structure and central
thrombosed capillaries (black dots).
There is an absence of normal
dermatoglyphics within the lesion.
• The main differential for a flat wart lobular structure
with central dots of
(bottom photo) is an SK. Flat warts common wart
can have dot or globular vessels and
even-colored light brown or yellow
patch. SKs will have a more "brain-
like" appearance.
even yellow to light
brown color of flat wart
Molluscum contagiosum
• Dermoscopy shows central inflamed
umbilication surrounded by crown molluscum
lesion
pattern of vessels (not crossing the
midline) and polylobular white to
yellow amorphous structures.
central umbilication

polylobular white to
yellow amorphous
structures
 Scabies
• Dermoscopy often reveals a thin
tract of white scale (the burrow)
with a small dark brown triangular
structure at the end of the burrow
called the delta (the scabies mite).
• Finding the delta sign clues us in on
positive scabies
the most high-yield area to scrape prep
to confirm on scabies mineral oil
prep (top left and bottom right
photos).

burrow with
delta sign
Herpes zoster
• Dermoscopy demonstrates multiple
confluent round cloudy white
polylobular structures with central
brown dots and surrounding
erythema. The brown dots are
surrounding
thought to correlate with erythema
multinucleated giant cells.

white polylobular
structures with
central black dots
 Tinea capitis
• Dermoscopy demonstrates black
dots, corkscrew and comma
hairs. KOH is positive for
endothrix (hair shaft was broken)
and spores within the hair shaft.
This correlates with the most
common causative organism in
U.S. (Trichophyton tonsurans) in
which black dots on clinical and
dermatoscopic exam are found. broken hair
shafts
positive KOH prep
 Tinea nigra
positive KOH prep
• Dermoscopy shows brown brown fine
granular dots
fine granular dots which do
not respect the anatomic
furrows or ridges of glabrous
skin.
References
1. Marghoob AA, Malvehy J, Braun RP. Atlas of Dermoscopy. 2nd ed.
London: Informa Healthcare; 2012.
2. Martín JM, Bella-Navarro R, Jordá E. Vascular patterns in dermoscopy.
Actas Dermosifiliogr. 2012 Jun;103(5):357-75.