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DERMOSCOPY: THE ESSENTIALS, THIRD EDITION ISBN: 978-0-7020-6882-9

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Preface to the Third Edition
As we prepare the third edition of Dermoscopy: The We are especially indebted to the Elsevier Editorial
Essentials, it has been 14 years since the first edition Team, Caroline Dorey-Stein and Charlotta Kryhl,
and 6 years since we last updated our guidebook to for their flexible support and patience during the
dermoscopy. With dermoscopy continuing to grow slow process of revising the book. We also thank our
in popularity as a physician’s tool, we are pleased to colleagues Dr Teresa Russo, Glen Wimberley and Katie
revamp our book and bring it to a new generation of Lee for their assistance in selecting and preparing the
dermoscopists. As always, it is a pleasure to collab- updated images and text.
orate with old colleagues and peers, though we are As with the earlier editions, we consign our
scattered around the world. We are able to work hand- book to all those interested in the science and art of
in-glove despite the vast distances with the miracle of dermoscopy and hope that we contribute to the lofty
modern technology and with the advantage of having goal of eradicating melanoma.
known each other and worked together for many H. Peter Soyer
years (over 20 years in some cases), and having been Brisbane, Australia
through many highs and lows together. Giuseppe Argenziano
This third edition continues to use the traffic Naples, Italy
light system to help practitioners quickly review Rainer Hofmann-Wellenhof
lesion categories during regular use and consolidate Graz, Austria
their knowledge, and to help new users absorb Iris Zalaudek
the skill of evaluating a whole lesion as well as its Trieste, Italy
component parts. We have substituted nearly 30% of 2018
the dermoscopic and clinical images to bring a fresh
set of clinically relevant examples to both novice and
experienced dermoscopists.
KEY TO TRAFFIC LIGHT SYMBOLS
High risk lesions
Moderate risk lesions
Low risk lesions
v
Acknowledgements
To my Oz-based team, Zoja and Niko, for both their To my “dermoscopy” friends and colleagues, to my
support and welcome distraction from my work. patients, and to my parents Ilse and Gunter, my sister
H. Peter Soyer Karin, my niece Lilith, and my nephew Arthur for
their love.
To my patients…to whom I have dedicated my life. Iris Zalaudek
Giuseppe Argenziano
To my teacher in dermoscopy and to my friends in

the field of dermoscopy. Special thanks go to my wife
Andrea and my children Elisabeth, Paul, Martin and
Georg, who have given me the strength to joyfully
work on the book.
Rainer Hofmann-Wellenhof
vii
DERMOSCOPY
The Essentials THIRD EDITION
H. Peter Soyer, MD, FACD

Professor and Chair,
Dermatology Research Centre,
The University of Queensland Diamantina
Institute,
The University of Queensland
and
Princess Alexandra Hospital,
Brisbane, Australia
Giuseppe Argenziano, MD
Professor of Dermatology,
Dermatology Unit,
University of Campania, Naples, Italy
Rainer Hofmann-Wellenhof,
MD
Research Unit for Teledermatology, Prevention
and
Innovative Diagnostic Technologies in Dermato-
Oncology,
Department of Dermatology,
Medical University Graz,
Graz, Austria
Iris Zalaudek, MD
Department of Dermatology and Venereology,
University of Trieste,
Trieste, Italy
Introduction: The 3-point
checklist
The short, easy way to avoid missing a melanoma using
1
dermoscopy
Other names for dermoscopy of patients with pigmented skin lesions, there is a
wide variety of products to choose from.
Dermatoscopy
Epiluminescence microscopy (ELM)
The 3-point checklist
Skin surface microscopy
To encourage clinicians to start using dermoscopy,
simplified algorithms for analyzing what is seen with
the technique have been developed.
Dermoscopy is an in vivo noninvasive diagnostic For the novice dermoscopist, the primary goal of
technique that magnifies the skin in such a way that dermoscopy is to determine whether a suspicious
color and structure in the epidermis, dermoepidermal lesion should be biopsied or excised. The bottom
junction, and papillary dermis become visible. This line is that no patient should leave the clinic with an
color and structure cannot be seen with the naked undiagnosed melanoma.
eye. With training and experience, dermoscopy has For the general physician, dermoscopy can be used
been shown to significantly increase the clinical to determine whether a suspicious lesion should be
diagnosis of melanocytic, non-melanocytic, benign evaluated by a more experienced clinician.
and malignant skin lesions, with a 10–27% improve- Dermoscopy is not just for dermatologists; any
ment in the diagnosis of melanoma compared to clinician who is interested can master this potentially
that achieved by clinical examination alone. There is, life-saving technique.
however, a learning curve to mastering dermoscopy,
and it is essential to spend time perfecting it—practice
Triage of suspicious pigmented skin lesions
makes perfect!
The 3-point checklist was developed specifically for nov-
ice dermoscopists with little training to help them not
Technique
to misdiagnose melanomas while improving their skills.
In classic dermoscopy, oil or fluid (mineral oil, Results of the 2001 Consensus Net Meeting on
immersion oil, KY jelly, alcohol, water) is placed over Dermoscopy (Argenziano G, J Am Acad Dermatol
the lesion to be examined. Fluid eliminates surface 2003) showed that the following three criteria were
light reflection and renders the stratum corneum especially important in distinguishing melanomas
transparent, allowing visualization of subsurface from other benign pigmented skin lesions:
colors and structures. Using handheld dermoscopes
• dermoscopic asymmetry of color and structure;
that exploit the properties of cross-polarized light
• atypical pigment network; and
(polarized dermoscopy), visualization of deep skin
• blue-white structures (a combination of the
structures can be achieved without the necessity of a
previous categories of blue-white veil and regres-
liquid interface or direct skin contact with the instru-
sion structures).
ment.
The list of dermoscopy instrumentation is long Statistical analysis showed that the presence of any
and continues to grow and evolve with the devel- two of these criteria indicates a high likelihood of
opment of better and more sophisticated handheld melanoma. Using the 3-point checklist, one can have
instruments and computer systems. Depending on the a sensitivity and specificity result comparable with
budget and goals for the evaluation and management other algorithms requiring much more training. In a
1
preliminary study of 231 clinically equivocal pig- Table 1.1 Definition of dermoscopic criteria for the
DERMOSCOPY – The Essentials
mented skin lesions, it was shown that, after a short 3-point checklist. The presence of two or three
introduction of 1-h duration, six inexperienced der- criteria is suggestive of a suspicious lesion
moscopists were able to classify 96.3% of melanomas
correctly using this method.
3-Point checklist Definition
This first chapter provides 60 examples of benign
and malignant pigmented skin lesions to demonstrate 1. Asymmetry Asymmetry of color and
how the 3-point checklist works and the practical structure in one or two
value of this simplified diagnostic algorithm. perpendicular axes
The 3-point checklist was designed to be used as 2. Atypical network Pigment network with
a screening method. The sensitivity is much higher irregular holes and thick
than the specificity to ensure that melanomas are not lines
misdiagnosed. We recommend that all lesions with 3. Blue-white structures Any type of blue and/or
a positive test (3-point checklist score of 2 or 3) are white color
excised (Table 1).
2
1
Introduction: The 3-point checklist

Checklist
Asymmetry
Atypical network
Blue-white structures
Total score 3
Fig. 1 Melanoma.
Criteria to diagnose melanoma can be very subtle or obviously present as in this case. This lesion clearly
demonstrates all of the 3-point checklist criteria, namely asymmetry in all axes, an atypical pigment net-
work (circle), and blue-white structures (asterisks).
Checklist
Asymmetry
Atypical network
Total score 0
Fig. 2 Nevus.
In contrast to Fig. 1, none of the features of the 3-point checklist are seen in this lesion. The lesion is
symmetrical, and the pigment network is regular, although it might seem to be atypical because the line
segments are slightly thickened. Also there is no hint of any blue and/or white color.
3
Checklist
Asymmetry
Atypical network
Total score 1
Fig. 3 Nevus.
The novice might find this lesion difficult to diagnose. If in doubt, cut it out! With experience, the clinician
will excise fewer of these banal nevi. There is asymmetry; however, neither an atypical pigment network
nor subtle blue-white structures are present.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 4 Melanoma.
Even for a beginner, the asymmetry of color and structure should be obvious. This asymmetrical lesion
also demonstrates blue-white structures (circle).
4
1

Checklist
Asymmetry
Atypical network
Total score 3
Fig. 5 Melanoma.
The color and structure in the lower half is not a mirror image of the upper half; therefore, there is asym-
metry. An atypical pigment network with thickened and broken-up line segments (circle) and a large area
of blue-white structures (arrows) are also seen.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 6 Melanoma.
This lesion is slightly asymmetric in shape and more in structure, and therefore, a red flag should be
raised. No pigment network is present, but there are numerous shiny white streaks (also called chrysa-
lis-like structures) (arrows) representing a variation on the theme of blue-white structures.
5
Checklist
Asymmetry
Atypical network
Total score 1
Fig. 7 Seborrheic keratosis.
This seborrheic keratosis demonstrates a great deal of asymmetry of color and structure, but the other
two criteria needed to diagnose melanoma are absent. If the multiple milia-like cysts (white arrows) and
the numerous follicular openings (black arrows) diagnostic of seborrheic keratosis cannot be recognized,
excise the lesion.
Checklist
Asymmetry
Atypical network
Total score 1
Fig. 8 Nevus.
Some melanomas are featureless, so beware! The color and structure in the left upper quarter of the
lesion is not a mirror image in any other quarter of the lesion. The presence of an irregular black blotch in
the left upper quarter (circle) adds to the asymmetry. An atypical pigment network and blue-white struc-
tures are not seen. In our estimation this is a nevus warranting careful consideration for its management.
6
1

Checklist
Asymmetry
Atypical network
Total score 0
Fig. 9 Nevus.
If in doubt, cut it out! With practice, fewer lesions that look like this will be excised. This is rather symmet-
rical, and there is a great example of a regular pigment network in the periphery of this banal nevus. Do
not be fooled by the dark central color—it is not always a sign of malignancy. No blue-white structures
are seen.
Checklist
Asymmetry
Atypical network
Total score 3
Fig. 10 Melanoma.
This lesion is a straightforward case of melanoma. The diagnostic criteria are striking, obvious asymmetry
of color and structure, a markedly atypical pigment network (arrows), and blue-white structures (circle).
7
Checklist
Asymmetry
Atypical network
Total score 1
Fig. 11 Nevus.
The clinical ABCDs could lead you astray with this banal nevus. There is slight asymmetry, but there is
also a typical pigment network fading out at the periphery and blue-white structures are absent.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 12 Melanoma.
This lesion is clearly asymmetric in color and in dermoscopic structure. No straightforward pigment net-
work is observed; however, blue-white structures (circles) are clearly seen throughout the lesion.
8
1

Checklist
Asymmetry
Atypical network
Total score 3
Fig. 13 Melanoma.
Clinicians might think that this lesion is nothing to worry about until they examine it with dermoscopy.
There is asymmetry of color and structure, an atypical pigment network, and blue-white structures (aster-
isks) cover part of the lesion.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 14 Melanoma.
The extensive blue-white structures (asterisks) are the first clue to the seriousness of this lesion. Particu-
larly color is clearly asymmetrical. A pigment network is absent, and there are well-developed blue-white
structures.
9
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 15 Basal cell carcinoma.
This lesion demonstrates nicely the in-focus arborizing vessels typical for a nodular basal cell carcinoma.
Two positive features of the checklist are clearly present—asymmetry and blue-white structures (arrows).
There is no pigment network.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 16 Melanoma.
Asymmetry is unmistakably present in this lesion, but whether the pigment network is atypical in several
foci of this lesion is debatable. Blue-white structures (circle) are clearly seen. There is no doubt this lesion
needs to be excised.
10
1
Checklist

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

Checklist
Asymmetry
Atypical network
Total score 2
Fig. 21 Nevus.
Another Spitz nevus–like pattern is demonstrated in this lesion, this time with hints of an atypical pigment
network in the left lower corner. Blue-white structures are visible throughout the lesion. A lesion like this
one should be excised without hesitation.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 22 Melanoma.
This rather banal-looking clinical lesion has a strikingly worrisome dermoscopic appearance, with asym-
metry of color and structure. No pigment network is present, but blue-white structures are seen through-
out the lesion (asterisks).
13
Checklist
Asymmetry
Atypical network
Total score 1
Fig. 23 Nevus.
This lesion is benign. Compare it with the other lesions shown in this chapter with more obvious asymme-
try of color and structure, an atypical pigment network, and blue-white structures. There is slight asym-
metry of color and structure, although 100% symmetry is never found in nature. No pigment network or
blue-white structures are seen.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 24 Nevus.
Two criteria of the 3-point checklist are present in this lesion, which should therefore be excised, at least
theoretically. There is slight asymmetry and an atypical pigment network covering most of the lesion. In
our experience it is difficult to predict if this lesion will be reported as dysplastic (Clark) nevus or as early
in situ melanoma. As our patient had several similar-looking lesions, we opted for close follow-up using
sequential dermoscopy imaging.
14
1

Checklist
Asymmetry
Atypical network
Total score 3
Fig. 25 Melanoma.
This is a clear-cut melanoma because of the striking asymmetry of color and structure and the presence
of diffuse blue-white structures (asterisks). An atypical pigment network can be discerned in the right part
of the lesion (circle).
Checklist
Asymmetry
Atypical network
Total score 2
There is no doubt that this pigmented neoplasm displays two criteria of the 3-point checklist. Note the
striking asymmetry. No pigment network is seen, but several blue-white structures are present (asterisks).
15
Checklist
Asymmetry
Atypical network
Total score 3
Fig. 27 Melanoma.
All three checklist criteria are seen in this lesion. There is significant asymmetry of color and structure
with a well-developed atypical pigment network (arrows). In the right lower part of the lesion, a blue-white
structure can be discerned (circle).
Checklist
Asymmetry
Atypical network
Total score 3
Fig. 28 Melanoma.
Significant asymmetry of color and dermoscopic structure can be easily recognized in this lesion. In
addition, there is a paracentrally-located blue-white structure (actually more whitish) and there are also
obvious foci of an atypical pigment network. This lesion needs to be excised.
16
1

Checklist
Asymmetry
Atypical network
Total score 1
Fig. 29 Nevus.
Only one of the checklist criteria is present in this lesion, so this lesion is benign. The lower half of the
lesion does not mirror the upper half, thereby displaying subtle asymmetry. No pigment network or blue-
white structures are seen.
Checklist
Asymmetry
Atypical network
Total score 1
Fig. 30 Nevus.
The presence of a single criterion from the checklist is usually not sufficient to diagnose malignancy.
Note the subtle asymmetry of color and structure—the left side of the lesion is not a mirror image of the
right side, and the upper side does not mirror the lower side. An atypical pigment network and blue-white
structures are absent.
17
Checklist
Asymmetry
Atypical network
Total score 1
Fig. 31 Melanoma.
This is a difficult lesion to interpret. Although only one criterion of the 3-point checklist is present, the
overall appearance may raise some suspicion that it could be a melanoma. The lesion is rather symmet-
rical and there is no pigment network. However, blue-white structures are clearly present throughout this
quite worrisome-looking lesion.
Checklist
Asymmetry
Atypical network
Total score 3
Fig. 32 Melanoma.
All criteria of the 3-point checklist are present, underlining the impression that this lesion is a melanoma.
Although the contour is symmetrical, there is asymmetry of color and dermoscopic structure within. Tiny
loci of subtle thickened pigment network are present at the upper pole of the lesion, with a small focus of
blue-white structures in the center of the lesion. This early melanoma might go undiagnosed if dermosco-
py is not used.
18
1

Checklist
Asymmetry
Atypical network
Total score 3
Fig. 33 Melanoma.
Once again, all three features of the checklist are clearly present and even a novice dermoscopist
should immediately suspect a melanoma. There is striking asymmetry of color and structure with zones
displaying an atypical pigment network (arrow). There are also clear-cut areas with another variation on
the theme of blue-white structures, namely peppering (asterisks).
Checklist
Asymmetry
Atypical network
Total score 2
The lower half of this lesion is not a mirror image of the upper half, and the right side is not a mirror image
of the left side; therefore, this is an asymmetrical lesion. No pigment network is identified, but there are
numerous blue-white structures seen throughout (circle). Remember, when two criteria are identified, the
lesion should be excised.
19
Checklist
Asymmetry
Atypical network
Total score 2
*
* *
*
*
Fig. 35 Nevus.
Despite the rather compelling asymmetry of color and structure, this lesion is benign. There is no hint of a
pigment network, but numerous blue-white structures are present (asterisks). With a score of 2, excise this
lesion or show it to a more experienced dermoscopist. Also remember to always compare the dermoscopic
features of several nevi of a given patient; every so often blue-white structures are found in several nevi of a
patient. Dermoscopic findings always need to be interpreted in the overall clinical context.
Checklist
Asymmetry
Atypical network
Total score 3
Fig. 36 Melanoma.
This is a difficult lesion to diagnose because there is a discrepancy between the clinical and the dermo-
scopic images. Dermoscopically all three features are present, albeit the atypical pigment network is very
subtle if at all present. Asymmetry is obvious, and blue-white structures can be seen clearly in the right
part of the lesion. If you have any doubt, the lesion needs to be excised.
20
1

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

Checklist
Asymmetry
Atypical network
Total score 3
Fig. 41 Melanoma.
This is a clear-cut example of a melanoma with a checklist score of 3. There is striking asymmetry of
color and structure. Several zones exhibit variations of the morphology of an atypical pigment network
(arrows). In paracentral location, blue-white structures can be clearly seen (asterisks). Always concentrate
and focus attention to identify important criteria that might be present in a lesion.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 42 Nevus.
Numerous foci of blue-white structures are seen throughout the lesion and we also scored asymmetry
here. An atypical pigment network is not seen. The dark color and blue-white structures are very worri-
some here and therefore we excised this lesion. This turned out to be a high-risk nevus, so it is better to
err on the side of safety and remove these borderline lesions.
23
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 43 Nevus.
This lesion is difficult to score and a score of 2 can be achieved for this lesion only if it is considered to
be asymmetrical. The pigment network is rather typical and is therefore not scored. There are, however,
subtle foci of blue-white structures in the center of the lesion.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 44 Seborrheic keratosis.
Strictly following the 3-point checklist gives this lesion a score of 2. There is slight asymmetry of color and
structure with a few areas of blue-white structures (asterisks). There is no pigment network. With a score
of 2, the novice dermoscopist should remove this lesion, though there will always be exceptions to every
rule. With experience, clinicians will become confident in diagnosing seborrheic keratosis.
24
1

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

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

Checklist
Asymmetry
Atypical network
Total score 2
Fig. 53 Nevus.
This lesion also has a checklist score of 2. This example shows the limitations of the 3-point checklist.
There is asymmetry because the lower half does not mirror the upper half. Also note that the pigment net-
work is atypical pretty much throughout the whole lesion. Blue-white structures are not observed. Please
remember your final management decision always needs to take into consideration the clinical context
including the morphologic features of other nevi in the same patient.
Checklist
Asymmetry
Atypical network
Total score 0
Fig. 54 Nevus.
This is a rather featureless lesion and we did not score this lesion at all. The slight asymmetry related to
the subtle area with a typical pigment network in the right upper corner was deemed not enough to call
this lesion asymmetric. And do not confuse the para central delicate hypopigmentation with blue-white
structures.
29
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 55 Melanoma.
There are two strikingly positive features present here—asymmetry and blue-white structures. Because
there are also a few satellite lesions (circle), it should be excised with high priority. Clear-cut asymmetry of
shape and structure and conspicuous blue-white structures (asterisks) are seen throughout the lesion. No
pigment network is seen, not even at the periphery.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 56 Nevus.
The atypical pigment network (circle) in this asymmetrical lesion is worrisome, and the lesion should be
excised. No blue-white structures are seen. Although the histology was benign, this dermoscopic picture
might also be seen in in situ melanoma.
30
1

Checklist
Asymmetry
Atypical network
Total score 2
The checklist score for this lesion is 2; because it is nodular, excision is recommended. Note the asymme-
try of color and structure and numerous blue-white structures throughout the lesion. No pigment network
can be identified.
Checklist
Asymmetry
Atypical network
Total score 2
Fig. 58 Nevus.
Two of the 3-point checklist criteria are present. Asymmetry of color and shape is evident, and centrally
located blue-white structures (circle) are seen. Because of a 3-point checklist score of 2, excision of this
lesion is recommended.
31
Checklist
Asymmetry
Atypical network
Total score 0
Fig. 59 Nevus.
The checklist score for this lesion is zero.
Checklist
Asymmetry
Atypical network
Total score 2
This nodular lesion scores 2, so it should be excised. There is a straightforward asymmetry of color and
structure. Please note the blue-white structures are clearly visible in the absence of a pigment network. In
addition, the typical arborizing vessels of basal cell carcinoma are present.
32
Pattern analysis
Dermoscopic criteria for specific diagnoses

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

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 62 Nevus.
Here is another example of the morphology seen with the reticular type of banal nevus. The quality of
the typical pigment network demonstrates darker and thicker lines. The benign nature of this lesion is
emphasized by the fading out at the periphery of the pigment network.
34
2
Pattern analysis
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 63 Nevus.
This is a reticular-type lesion with a few dots. Please note in the center of the lesion, the pigment
network is lacking. In addition, there are a few brown dots (also called clods) at the periphery; an
indication that this nevus is still growing. This lesion can also be called a Clark, dysplastic, or atypical
nevus; it is not a melanoma.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 64 Nevus.
This lesion is characterized by a rather typical pigment network. Closer scrutiny reveals several brown-
ish to bluish dots (clods) in the central and paracentral part of this lesion. As a general rule in reticular
lesions, which are not palpable, clinically the differentiation between a junctional and a compound nevus
is not possible dermoscopically.
35
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 65 Nevus.
A reticular-homogeneous pattern, as seen here, can be seen in banal nevi. In the center, there is ho-
mogeneous black pigmentation (black lamella), and at the periphery there is an annular distribution of a
typical pigment network. Once again, the pigment network fades at the periphery—a sign of a benign na-
ture. If this was a solitary lesion, in situ melanoma would be the differential diagnosis. Most people with
this dermoscopic appearance have multiple similar-appearing nevi, favoring low-risk pathology. Tape
stripping can peel away the black lamella and allows one to see whether there are any underlying typical
or atypical structures.

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

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 68 Nevus.
The patchy reticular pattern shown here is associated with an uneven distribution of a typical pigment
network. The intensity of pigmentation of the lines alternates, giving this pigment network a patchy
appearance. The general principle to remember is that any unevenness of a relatively regular-appearing
pigment network is a minor cause for concern. Please note the whitish halo around a hair at the lower
left pole of the lesion. This is a rather common finding in reticular nevi.
37
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 69 Nevus.
This nevus shows a variation of reticular-pattern morphology. Note the zone of homogeneous hypopig-
mentation in upper half of the lesion. This is not an area of regression that would be seen in melanoma.
Still, this lesion is clearly asymmetric in shape and dermoscopic structure and therefore this lesion was
excised and called a high-risk nevus. Always remember: when in doubt cut it out.

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

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 72 Nevus.
This is most probably a nevus with a complex overall dermoscopic pattern revealing the characteristics
of a reticular and a globular nevus (left pole). This lesion displays several unusual dermoscopic aspects
with prominent blue-white structures (more bluish-black) in the center. Always excise a lesion like this
one. The histopathology diagnosis here was a dysplastic (Clark) nevus, compound type.
39
Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 73 Nevus.
This light-brown pinkish lesion reveals a central hypopigmented homogeneous area surrounded by a
subtle, not very pronounced pigment network in a ring-like fashion. The unusual aspect of this lesion
is its pinkish color, and in the absence of any history of growth, annual follow-up is the management
approach we choose for this patient.

Reticular pattern
Globular pattern
Homogeneous pattern
Starburst pattern
Fig. 74 Nevus.
This lesion can be regarded as a typical example of a reticular melanocytic proliferation. There is a cen-
tral zone of hyperpigmentation. The pigment network has rather regular qualities throughout the lesion.
However, it does not thin out nicely along the periphery as commonly observed in reticular nevi. Because
of this dermoscopic finding and heavy pigmentation, this is potentially a high-risk lesion. Histopatholog-
ically, this was diagnosed as a junctional type of dysplastic (Clark) nevus. Novice dermoscopists should
not hesitate to excise lesions that look like this.
40
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doing they may be considered in connection with the remarks of their
critics and a just comparison made. In presenting the views of
Quaker educators reference may be made to salient points in the
criticism, which seem out of keeping with the ideas set forth and
without foundation as matters of fact.
There are quite a number of men, in the brief [Sidenote: Only a
period studied, who stand out clearly and express few of the leaders’
themselves definitely in favor of education, though statements to be
considered]
they do not consider it the first requisite for a
minister of the gospel.[76] From this number it will be feasible to
select only a few for the chief consideration, relegating the remainder
to a place of comparative unimportance and incidental notice. The
work of George Fox, though he was poorly educated, had a
remarkable effect on the educational work of the society. But it is not
necessary to review that in the present chapter as it has been
presented in the first.[77]
By far the most familiar of all characters in Quaker history is that of
William Penn. And to his influence must be attributed largely the
hearty interest in education shown, not only in Philadelphia, but also
in the surrounding communities. He was well educated, but it is not
desired to make a case for or against him on the basis of his
education; let us judge by his written or spoken expression and
actual procedure in practice. No attempt is made to prove or
disprove his contentions as to what was right or wrong, necessary or
unnecessary in education. The questions asked in his case and the
others that follow is: What did they approve or disapprove of in
education?
Not only in works that might be called strictly [Sidenote: Penn
educational did Penn give educational advice, recommends
valuable alike to youth and to parents, the directors practical virtues]
of youth. His advice to his children on the value of
diligence and its necessity for success, and the propriety of frugality,
even in the homes of the rich, embodies many of the most essential
principles in education at any time. It is especially applicable to the
education of the man of business, emphasizing the importance of the
practical duties in life. Some pointed statements are especially
worthy of repetition.
[Sidenote:
Diligence ... is a discreet and understanding Diligence]
application of onesself to business; ... it loses
not, it conquers difficulties.... Be busy to a [Sidenote:
Frugality]
purpose; for a busy man and a man of business
are two different things. Lay your matters and diligence
succeeds them, else pains are lost.... Consider well your end,
suit your means to it, and diligently employ them, and you will
arrive where you would be....[78] Frugality is a virtue too, and
not of little use in life, the better way to be rich, for it hath less
toil and temptation.... I would have you liberal, but not
prodigal; and diligent but not drudging; I would have you
frugal but not sordid.[79]
This bit of philosophy is educational in its bearing in very much the

same way as that of Benjamin Franklin.
In the letters to his wife and children, referring to the care for their
education, he is more specifically concerned with actual school
education.
[Sidenote: School
For their learning, be liberal. Spare no cost, education
for by such parsimony all is lost that is saved; recommended;
but let it be useful knowledge such as is the useful
emphasized]
consistent with truth and godliness, not
cherishing a vain conversation or idle mind; but ingenuity
mixed with industry is good for the body and the mind too. I
recommend the useful parts of mathematics, as building
houses, or ships, measuring, surveying, dialing, navigation;
but agriculture especially is my eye. Let my children be
husbandmen and housewives; it is industrious, healthy,
honest and of good example, ...[80]
His preference, as might be expected from an [Sidenote: Private
Englishman of that time, was for a tutorial system tutors desired]
of education. His reasons therefore seem to have
been based chiefly on moral grounds.
Rather have an ingenious person in the house to teach

them, than send them to schools; too many evil impressions
being received there.[81]
The above quotation alone would seem to be adequate proof that

Penn did not oppose education, but urged it for others and in his own
family. But still more convincing and irrefutable evidence is found in
the preamble to this school charter, whence an extract is taken.
[Sidenote: Public
Whereas, the prosperity and welfare of any education
people depend in great measure upon the good essential for the
welfare of a
education of youth, and their early instruction in people]
the principles of true religion and virtue, and
qualifying them to serve their country and themselves, by
breeding them in writing and reading and learning of
languages, and useful arts and sciences, suitable to their sex,
age and degree; which cannot be effected in any manner or
so well as by erecting public schools for the purposes
aforesaid, therefore....[82]
If, as must be admitted, the previous statement [Sidenote: His

points out the lack of any opposition to the ordinary ideals expressed
rudimentary education that is necessary for the in action]
everyday walks of life, the last one certainly does [Sidenote: Yearly
the same in reference to his attitude towards a meeting
higher classical education. Moreover, this is not a recommend
French, High and
mere skeleton of words never clothed with the flesh Low Dutch,
of action. The principles set forth in the charter Danish, etc.]
were actually incorporated in the work of the
schools established in Philadelphia, and we find them maintaining a
classical school for languages and higher mathematics.[83] The
practical elements received the just emphasis which belonged to
them; it was necessary that the boys and girls be made able to earn
a living and be at least ordinarily intelligent citizens. The example of
Philadelphia was followed by other communities; practical needs
were given the first consideration and a higher classical education
offered when it became possible. Not only were these studies, which
we would term higher education, mentioned by Penn and other
writers among Quakers, but they were taken up and recommended
by the yearly meeting. For example, in 1737, the minutes
recommend that as opportunity can be found, children should be
privileged to learn “French, High and Low Dutch, Danish, etc.”[84]
This particular recommendation was made by the meeting because
of a felt need.[85] If then in case of a need for a particular subject,
they were willing to recommend that it be taught, can it be truly said
that they opposed all education?
It may be well to examine Barclay, since it is with [Sidenote:
him and his writings that Cox takes issue. In his Barclay’s position
Apology for Christian Divinity Vindicated is to be defined]
found a very clear statement of his position on the
subject, and he voices it as the principle of the whole society as well.
He seems to be answering some critic, who has taken him to task for
his educational views:
[Sidenote: In his
He goes on after his usual manner saying, I Apology]
inveigh against all human learning that has
been made use of any ways in Theology; but where he finds
this asserted I know not, whether the words he would declare
it from, to wit: that man hath rendered the plain and naked
truth obscure and mysterious by his wisdom, will bear such a
consequence is left to the reader’s judgment. But he thinks he
has found out our secret design of being against learning and
schools of learning, which is neither our affirmation nor our
principle, but his own false supposition. We would, saith he,
have all those banished, that we might more easily prevail
with our errors. But methinks the man should be more wary in
venting his own false imaginations, unless he would bring
some ground for them; for his assertion is so far untrue, that if
he had been rightly informed, he might have known that we
have set up schools of learning for teaching of the languages
and other needful arts and sciences,[86] and that we never
denied its usefulness; only we denied it be a qualification
absolutely necessary for a minister, in which case alone we
have opposed its necessity.[87]
Another character of very great importance in [Sidenote:

this connection is Anthony Benezet. Born, 1713, at Benezet’s early
St. Quentin in France, of “an ancient and life and education]
respectable family” he spent his early years in
France and then in Holland, whither his father had fled for refuge.[88]
A few months were spent in Rotterdam and the family then moved to
London where the father entered into the mercantile business and
retrieved to some extent his fallen fortunes. This enabled him to give
Anthony sufficient education to qualify him for that business, for
which, however, he seemed to evince but little taste. Being of a very
religious nature, he became a member of Friends at about fourteen
years of age, and in that society found the field of his whole life’s
activity, which was chiefly educational.[89] Considerable space will be
devoted to his work in respect to the education of Negroes, so that
will be entirely omitted in this place.[90] He was a voluminous writer,
producing chiefly tracts and letters, and a great majority of these
have a definite educational bearing. Because of the great number of
them it is impossible really to do them justice, but an attempt will be
made to state a few brief theses for which he unchangingly stands.
First, education is a religious and social duty.[91] [Sidenote:
It is exceedingly interesting to notice that he looks Education a
function of
upon education as in the first place a governmental government, but
function, if the governments of this world were often neglected
influenced by true wisdom, they would make the as such; hence
individual effort
proper education of youth their first and special necessary]
care;[92] but since governments have neglected to
do this, it occurs to him that it is a service for which Quakers are
remarkably well fitted. It is a service for which the wage is very small
and which secures no return of special social favors for the laborer.
But they, being a quiet people, not wishing to gain great wealth or to
shine in social positions, can find their sphere of activity in the
education of the youthful members of society.
Second, a special care in the education of the [Sidenote:
poor is urged.[93] This should become the duty and Children
represent
secure the interest of the well-to-do public spirited “capital”; they
man, for if the upper class does not safeguard it, must be
they cannot be educated. The poor child educated]
represents so much unimproved property, the
owner being unable to improve it, which, if taken over by
philanthropists, may become of some consequence to himself and
perform great services for society at large. Such a movement would,
besides being a great aid to the poor and uneducated, be also a
worthy occupation for those who at present have nothing but time
and money to spend. It would help them to realize that there is
something real in the world, something greater than wealth and
broader than religious denominations. The heart of Benezet knew no
bounds; in his philanthropy he included all classes.
Third, a definite stand is made for higher standards for teachers.
I do not know how it is amongst you, but here any person of

tolerable morals, who can read and write, is esteemed
sufficiently qualified for a schoolmaster; when indeed, the
best and wisest men are but sufficient for so weighty a
charge.[94]
He endeavors to show that the work of a teacher is pleasant and

should interest a better class of masters than it has in the past. The
experiences of Benezet in the school work were of most pleasant
nature. Not only by his own statement, but judged also by the
accounts given in his memoirs by Robert Vaux, it seems that he was
unusually kind and sympathetic as a master, which won him the
greatest respect of his pupils.[95] The tasks of schoolteaching are
only unpleasant when being performed merely for the sake of the
wage obtained. Those who attempt to teach large numbers for the
sake of a large income find it disagreeable; they form the class of
teachers against whom he would discriminate.[96] Add to these three
principles, his great contribution toward the freedom and education
of the Negroes, his long life of service, and we have all for which he
lived. It is stated that he had no private life; at any rate it sinks into
oblivion in comparison with his interest and active work in public
philanthropies.[97]
The educational influence of John Woolman in [Sidenote: John
regard to Negro and Indian education will be Woolman, his
position in regard
mentioned in another chapter,[98] but concerning to education]
education generally he was equally outspoken, and
being a member of some consequence he was [Sidenote: The
able to make his influence felt. Like Benezet, he responsibility
tutors and
of
regarded education as a social duty, both to each parents]

individual and to the community of individuals. This
duty could not be performed by immoral tutors and schoolmasters,
for the pupil could be made to rise no higher than the master; so the
result would be an immoral society.[99] The responsibility, in the last
analysis, for the right conduct of schools falls upon the parents. If
they are indifferent, nothing can be accomplished for the schools, for
the whole community is no better or more insistent in its demands
than the individuals constituting it. For this reason he urges individual
philanthropy to come to the aid of the schools, which are badly
neglected; those who possess wealth can do no better, for, as he
says:
Meditating on the situation of schools in our provinces, my

mind hath, at times, been affected with sorrow, and under
these exercises it hath appeared to me, what if those that
have large estates were faithful stewards, and laid no rent or
interest nor other demand, higher than is consistent with
universal love; and those in lower circumstances would under
a moderate employ, shun unnecessary expense, even to the
smallest article; and all unite humbly in seeking the Lord, he
would graciously instruct and strengthen us, to relieve the
youth from various snares, in which many of them are
entangled.[100]
If to this list of advocates of education, it is [Sidenote: Tuke,

necessary to add others, mention should be made Whitehead,
of Henry Tuke, George Whitehead, and William Crouch as
advocates of
Crouch. In defending certain differences between education]
the Quaker doctrine and that of other
denominations, the former discusses this one, in not considering
human learning essential to a minister of the gospel.[101] The
reasons adduced are chiefly biblical; the knowledge of human
literature is not recommended by the New Testament as being
necessary for a minister, and this is considered conclusive proof.
Moreover, it is pointed out that Paul, though a well educated man,
disclaimed the value of his education for that service, and wished
always to appear to the people as an unlettered man of God.[102] But
Tuke goes on to explain that though it is not essential for a minister,
learning is not unesteemed nor its usefulness slighted.[103] Members
are desired to direct their attention to education, for a right use of it
may promote religion and benefit civil society.[104] That the use of
Latin and Greek is not decried may be seen in the work of Penn and
Whitehead, who were both scholars, and whose works are full of
classical references and illustrations. In one instance their chief
argument against swearing is produced from certain references to
the works of Socrates and Xenocrates, pointing out that the Greeks
were aware of a higher righteousness excelling that of the legal
Jews.[105] The same point of view with reference to a knowledge of
the classics is taken by William Crouch, as is understood at once by
this statement:
They acknowledge the understanding of languages,

especially of Hebrew, Greek and Latin, formerly was and still
is very useful, yet they take them not therefore to be
necessary to make a minister nor so profitable as that one
unacquainted with them must be styled an idiot, illiterate and
of no authority.[106]
Moreover, from various sources one is assured [Sidenote: The

that a classical education was not abhorred by the Latin School of
Quakers of Philadelphia. The work offered in the Philadelphia
exemplifies
classical school was for any one who had the contention of
ability to do it and its attainment was encouraged those quoted
by Friends. The higher education was for girls as above]
well as for boys, as we may judge from reading the [Sidenote:
journal kept by Sally Wister (or Wistar), a Quaker Education an
girl of the days of the Revolution.[107] She attended asset; but apt to
be perverted]
the school kept by Anthony Benezet,[108] which
was one of the highest class, moral and literary, and patronized by
the best classes of the citizens. Extracts from her Journal indicate
that her education had not been limited to the mere rudiments, but
that she enjoyed also an elementary knowledge, at least, of Latin
and French.[109] This sort of education was clearly not uncommon
among Friends and it was not the object of opposition on their part. It
must, however, be kept in mind that the Quakers never confused
education necessarily with true Christianity.[110] Religion in this life
and the salvation of one’s soul in the next was a problem which
concerned the poor as well as the rich, the untutored as well as the
learned. How could the demands be greater for one than the other;
the same tests had to be met and passed by all, the educated one
received no favors though more might be expected of him.[111]
Education was looked upon as an asset which might be turned to
great use for Christianity, but the lack of it was never a bar to
Christianity.[112] On the other hand, education might easily become,
according to the Quakers’ views, a definite hindrance to Christianity.
[113]
It would be quite improper in connection with this [Sidenote:

subject to fail to mention the scheme, Utopian in Scheme of
that day, which was conceived in the mind of education
Thomas Budd, for the development of a system of suggested by
Thomas Budd]
education for Pennsylvania and New Jersey. At the
very outset it seems more comprehensive than anything suggested
by any other leader, and in fact it embodied so much that it was quite
beyond the limit of expectation for either of the colonies. Thomas
Budd, though not at first a member of Friends, became convinced of
the justice of their principles and joined the society before the year
1678.[114] He was a man of affairs and became greatly interested in
the colonization of Pennsylvania and New Jersey, whither he soon
came as a colonist himself. At that time it was equally true, as at the
present, that if a scheme or undertaking was to be put through, it
must be made as attractive as possible to the prospector. The
attempt to do this called forth a considerable exercise of individual
initiative, and one result was the educational plan outlined by
Thomas Budd and published in Philadelphia in 1685. The details of
the scheme as outlined are deemed of sufficient interest and
importance to warrant their reproduction here.
[Sidenote:
1. Now it might be well if a law were made by Children to be in
the Governors and General Assemblies of public school
Pennsylvania and New Jersey, that all persons seven
more]
years or
inhabiting the said provinces, do put their

children seven years to the Public School, or longer, if the
parent please.
2. That schools be provided in all towns and [Sidenote: To

cities, and persons of known honesty, skill and receive instruction
understanding be yearly chosen by the in the arts and
sciences and to
Governor and General Assembly, to teach and learn a trade]
instruct boys and girls in all the most useful arts
and sciences that they in their youthful capacities may be
capable to understand, as the learning to read and write true
English and Latin, and other useful speeches and languages,
and fair writing, arithmetic and bookkeeping; the boys to be
taught and instructed in some mystery or trade, as the making
of mathematical instruments, joinery, turnery, the making of
clocks and watches, weaving, shoemaking or any other useful
trade or mystery that the school is capable of teaching; and
the girls to be taught and instructed in spinning of flax and
wool, and knitting of gloves and stockings, sewing, and
making of all sorts of useful needlework, and the making of
straw work, as hats, baskets, etc., or other useful art or
mystery that the school is capable of teaching.
3. That the scholars be kept in the morning [Sidenote: Eight

two hours at reading, writing, bookkeeping, etc., hours per day
and other two hours at work in that art, mystery allotted to studies
and chosen trade]
or trade that he or she most delighteth in, and
then let them have two hours to dine, and for recreation and
in the afternoon two hours at reading, writing, etc., and the
other two hours at work at their several employments.
4. The seventh day of the week the scholars [Sidenote:

may come to school only in the forenoon, and at Regular school
a certain hour in the afternoon let a meeting be work five and
one-half days per
kept by the schoolmasters and their scholars, week; moral
where good instruction and admonition is given instruction on
by the masters to the scholars and thanks Saturday]
returned to the Lord for his mercies and
blessings that are daily received from him, then let a strict
examination be made by the masters, of the conversation of
the scholars in the week past, and let reproof, admonition and
correction be given to the offenders, according to the quantity
and quality of their faults.
5. Let the like meetings be kept by the school [Sidenote: Similar

mistresses, and the girls apart from the boys. arrangement for
By strictly observing this good order our girls educated
separately]
children will be hindered from running into that
excess of riot and wickedness that youth is incident to, and
they will be a comfort to their tender parents.
6. Let one thousand acres of land be given
and laid out in a good place, to every public [Sidenote: Land
endowment for
school that shall be set up, and the rent or schools]
income of it to go towards the defraying of the
charge of the school.
7. And to the end that the children of the poor [Sidenote: Indians
people, and the children of Indians may have and the poor to be
the like good learning with the children of the educated
cost]
free of
rich people, let them be maintained free of

charge to their parents, out of the profits of the school, arising
by the work of the scholars, by which the poor and the Indians
as well as the rich, will have their children taught, and the
remainder of the profits, if any be to be disposed of in the
building of the schoolhouses and improvements on the
thousand acres of land, which belongs to the school.[115]
The author does not claim to be entirely original [Sidenote: The

in his scheme, having been influenced, he says, by industrial and
a similar thing described by Andrew Yarenton in a commercial
values to be
book, England’s Improvements by Sea and Land. derived are
[116] His chief interest seems to be in the benefit to pointed out]
be derived for the commercial life of the colonies,
and for that reason there is accordingly a great stress on the
industrial education. By this introduction of the industrial schools,
spinning for example, in the larger cities and the preparation of
children at an early age for participation in that great occupation, the
production of linen cloth could be made equal not only to the
domestic demands but also a considerable margin for the foreign
trade.[117] It is pointed out that the colonial consumer pays twice as
much for his purchase as its cost of production in France or
Germany, and that he pays this extra cost into the coffers of the
English merchants. This profit should accrue to the home merchants.
The educational and also the industrial scheme [Sidenote:
is to receive the backing of the colonial Scheme to be
government. It is recommended that laws be
passed for the encouragement of linen encouraged by
manufacturers and that farmers “that keep a plow” the government]
should sow an acre of flax and two of hemp, with [Sidenote:
which to supply the manufacturers.[118] Educational Essential points
urged in the
support by the government was not secured, as is scheme]
amply evidenced by the unsurpassed development
of private and parochial schools of all [Sidenote: The
denominations. The churches were the sponsors lack of
governmental
for education. It is worthy of note, however, that the support; supplied
elements emphasized by Budd, (1) education in the through meetings
arts and sciences for all those capable of it, (2) of Quakers]
industrial education for a trade for every one, (3)
moral and religious training, and (4) equal educational opportunities
for poor and rich or otherwise unfavored classes, are the same as
those urged officially by the Quakers.[119]
Far from receiving governmental support, it was necessary that
the schools be supported by individual or small group enterprise.
The society recognized this, and it is stated in the organization of the
church that the duty of the monthly meeting is to provide for the
subsistence of the poor and for their education.[120] Furthermore it is
recommended that all special bequests of Friends be kept as a
distinct fund for the purpose originally intended by the donor, and
that if expended for any other purpose, it must be again made up by
the quarterly meeting.[121] One of the most frequent uses
designated, judging from the records, seems to have been the
educational.[122]
The reader may have perused the foregoing [Sidenote: Have
pages with more or less interest; a curiosity may Quaker schools
have been aroused concerning the present-day kept pace with the
public?]
attitude of Friends, educationally. Have they
experienced any considerable change? The institutional evidences
of their continued interest are familiar enough to the educationist. But
what is the attitude within the schools: Is instruction stiff and more
formal there than in the public schools, and what can be said of the
progress among the teachers? To answer all of these questions and
similar ones is not the purpose of this present work. And in the
following excerpt, taken from an expression drawn up by a body of
teachers, it is not hoped to find conclusive proof of this or that, but
perhaps it may be taken as a fairly reliable indication of the present
professional attitude.
[Sidenote: The
The teachers’ subjects are not Mathematics, pupil as an
nor Latin, nor Scripture, nor Quakerism—they individual to be
emphasized]
are boys and girls. The information imparted is,
in a sense, a minor matter: the growth of the [Sidenote: Well-
mind that assimilates it is all-important—growth equipped
teachers needed;
in keenness, efficiency and power.... and their
To the Society at large we would put forward academic
freedom
this view that the principles urged above are essential]
deserving of careful consideration in making
any forward move. The quality of the teaching given in our
schools is in a measure in the hands of Friends; they have
raised admirable buildings in many places—these are a small
matter compared with the character of the staff. The freedom
of the teacher, which is an indispensable condition of
excellence is a gift they can grant or withhold. And that we
who are responsible for the term of school life may have the
best chance and the best reward, we would press upon
Friends the need of laying foundations and awakening
interest in the days of childhood, and of turning to best
account the powers of those who go forth from our schools.
[123]
SUMMARY
This chapter treats of the attitude of Friends [Sidenote:
towards education. At the beginning there is Summary of
presented a criticism of S. H. Cox, which is a Cox’s position]
concrete example of the type of criticism referred to
in these pages. Following this there are presented the educational
views of several Friends,—Penn, Barclay, Benezet, Woolman,
Whitehead, Crouch, Tuke, and Thomas Budd, in order that the
reader may judge of the truth or error presented in the criticism. The
chief points made in Cox’s criticism are: (1) hostility of the Quaker
system to classical education, (2) general hostility of the Friends to
colleges and seminaries of learning, and (3) that the “light within”
was sufficient without any education.
From the material next presented it is shown [Sidenote:
that: (1) Penn recommended both practical and Summary of
higher education, (2) useful arts and sciences are points maintained
by certain Quaker
recommended to be taught in public schools, (3) leaders]
the classics were introduced as a part of the
curriculum in the Penn Charter School, and also in other schools
established by the society, (4) Barclay explains that the society holds
a classical education not absolutely necessary for a minister, though
it is useful, (5) the learning of languages is recommended by the
London Yearly Meeting, (6) education is advocated by Benezet as a
religious and social duty; the education of the poor and unfortunate
classes and races is urged; a higher education for schoolmasters is
recommended, (7) Woolman urges the education of Negroes and
Indians as a social duty; the responsibility is placed on the individual,
(8) Crouch states that Hebrew, Greek, and Latin are recognized as
useful and are not opposed when taught for that purpose, (9) Budd,
one of the early Quakers in Pennsylvania, introduced a very
comprehensive and Utopian scheme for (a) industrial education and
(b) higher education, proposing to organize it under the control of the
General Assembly, and (10) indications are that progress, within the
teaching body in Friends’ institutions, is quite comparable with that of
other institutions, though there is no attempt to produce conclusive
evidence either to that effect or the contrary.
CHAPTER IV
EDUCATION IN PHILADELPHIA[124]
On ye 27th day of October, 1682, arrived before ye Towne

of New Castle from England, William Penn, Esqe., whoo
produced twoo deeds of feofment for this Towne and twelve
myles about itt, and also for ye twoo lower counties, ye
Whoorekills and St. Jones’s—wherefore ye said William Penn
received possession of ye Towne ye 28th of October, 1682.
[125]
It is probable that Penn reached Philadelphia in [Sidenote: The

the latter days of October or the early part of date of Penn’s
coming disputed]
November,[126] though no student of Philadelphia
history has yet been able to settle the question of the day absolutely.
Tradition says he came up the river in an open boat and landed at
the landing on Dock Street near the new tavern, the Blue Anchor,
which had just been erected by George Guest, a Quaker.[127] The
formal ceremony of transferring the territory which had been
arranged between Penn and the Duke of York before leaving
England,[128] was accomplished with the Duke’s commissioners,
Moll and Herman,[129] and the official debut of Pennsylvania in
colonial society was no longer a hope but a reality.
The foundation of the colony’s educational [Sidenote:
institutions had, however, not been delayed till the Education
formalities of “making” a colony were over. provided for in
first Frame of
Education received early consideration in the Government]
Frame of Government which was drawn up from
England by Penn and agreed to on April 25, 1682, before he
prepared to depart for Pennsylvania.[130] In that document it is
clearly set forth that education was the function of the civil authority,
though the intentions of the author were not realized fully for more
than a hundred and fifty years.[131] The same idea is present in each
of the three Frames of Government which were drawn up; the first,
April 25, 1682;[132] the second, April 2, 1683;[133] and the third,
November 7, 1696,[134] under Governor Markham. The instrument
drawn on April 2, 1683, contained in part the following stipulations,
which bear the impression of the Quaker ideal of education.
[Sidenote: The
Tenth. That the Governor and the Provincial provisions]
Council shall erect and order all public schools
and encourage and reward the authors of useful sciences and
laudable inventions in the said provinces and territories
thereof.
Eleventh. That one-third of the Provincial Council residing
with the Governor from time to time shall, with the Governor,
have the care and management of public affairs relating to
peace, justice, treasury and improvement of the province and
territories, and to the good education of the youth, and
sobriety of the manner of the inhabitants therein aforesaid.
[135]
The plan for education as above set forth was [Sidenote: Quaker
not destined to be the one followed consistently for Council provides
more than a century and a half of development, a school]
though throughout the first decades the relations
between the schools of Friends and the governing Council were very
close.[136] It is significant that the first school was actually ordered by
the Council, in keeping with Penn’s provisions. About one year after
Penn’s arrival in Philadelphia the educational problem came to the
attention of the Council and received decided recognition, as the
following witnesses:
The Governor and Provincial Council having taken into their

serious consideration the great necessity there is of a
schoolmaster for the instruction and sober education of the
youth in the town of Philadelphia, sent for Enock Flower, an
inhabitant of said town, who for twenty years past has been
exercised in that care and employment in England, to whom
having communicated their minds, he embraced it upon the
following terms: to learn to read English 4s by the quarter, to
learn to read and write 6s by the quarter, to learn to read,
write and cast accounts 8s by the quarter; for boarding a
scholar, that is to say, diet, washing, lodging, and schooling,
ten pounds for one whole year.[137]
Thus the first impetus to education in [Sidenote:

Pennsylvania came through properly constituted Additional
governmental authority. The Council records show provisions or
books]
that the interest in educational affairs was
maintained for some time. In the month following a [Sidenote: Charter
law was proposed for making several sorts of of 1701 does not
refer to education
books for the use of persons in the province, and as did the former
also recommended that care be taken about ones]
“Learning and Instruction of youth, to witt: a school
in the arts and sciences.”[138] This interest in, and the close relation
of the Council to, education were not long continued however; for
this there is no satisfactory explanation, though it is very clear that
the attitude on the part of the government did change.[139] This
change is evidenced in the policy as outlined by the Charter of 1701,
in which there is no reference made to education or the responsibility
of the Governor or Council therefor.[140] To the writer it seems that
the withdrawal of the Council from any very active participation in the
affairs of education may have been due to two reasons: first, the
willingness evinced by private interests to establish schools and thus
take over to themselves the duties of educators (evidenced by the
establishment of Keith’s school by Friends in 1689 without the
assistance or advice of the Council);[141] and second, the urgent
details of establishing a new government, which occupied their first
attention.
If further proof of the withdrawal of the colonial government from
the active establishment of schools, and of the fact that they did
accept and recognize the assistance of private agencies is desired, it
is to be found in various acts of legislation of the first half century.
Specific instances of such permissive legislation were the acts of
May 28, 1715,[142] and also of February 6, 1730-1.[143] This
legislation is chiefly concerned with granting privileges to purchase
and hold land and erect buildings for the use of institutions stated
therein, among which schools are mentioned. In this connection the
statute of 1715, which evidences the facts stated above, is quoted.
Be it enacted by Charles Gookin, Esq., by the royal

approbation Lieutenant-Governor, under William Penn, Esq.,
Proprietary and Governor-in-Chief of the Province of
Pennsylvania, by and with the advice and consent of the
freemen of the said provinces in General Assembly met, and
by the authority of the same, that it shall and may be lawful to
and for all religious societies or assemblies and
congregations of Protestants, within this province, to
purchase any lands or tenements for burying grounds, and for
erecting houses of religious worship, schools and hospitals;
and by trustees, or otherwise, as they shall think fit, to receive
and take grants or conveyances for the same, for any estate
whatsoever, to and for the use or uses aforesaid, to be holden
of the lord of the fee by the accustomed rents and services.
And be it further enacted by the authority aforesaid, that all
sales, gifts or grants made to any of the said societies, or to
any person or persons in trust for them, or any of them, for or
concerning any lands, tenements or hereditaments within this
province, for and in any estate whatsoever, to and for the use
and uses aforesaid, shall be and are by this Act ratified and
confirmed according to the tenor and true meaning thereof,
and of the parties concerned therein. And where any gifts,
legacies or bequests have been or shall be made by any
person or persons to the poor of any of the said respective
religious societies, or to or for the use or service of any
meeting or congregation of the said respective societies, the
same gifts and bequests shall be employed only to those
charitable uses, or to the use of those respective societies or
meetings, or to the poor people to whom the same are or
shall be given or intended to be given or granted, according to
what may be collected to be the true intent and meaning of
the respective donors or grantors.
On “11th month, 9th, 1682,” the Friends met and [Sidenote: The
enacted business relating chiefly to the sick, a first meeting of
meeting house, purchase of books and such other record]
details of importance, but made no reference to [Sidenote: The
schools or the education of youth.[144] This probable length of
Flower’s tenure
remained true for all meetings till 1689,[145] the as teacher]
chief part of business in the meantime having to do
with either (1) strictly religious affairs or (2) raising money for the
poor and the orphans. The absence of any remarks or any plans for
schools from 1682 to 1689 is more easily understood when it is
recalled that the school under Enock Flower was set up in 1683.[146]
There is no evidence to prove definitely that Flower continued as
schoolmaster during the whole of this time, but (1) the absence of
any record of change, (2) no record of schools kept by the Friends
Meeting, (3) the fact that he was a teacher of long experience
(twenty years) and probably as satisfactory as any to be found, and
(4) the absence of keen competition on the part of neighboring
places to draw him away, would lead one to believe it probable that
he remained there for the greater part of the period at least.
In 1689 Friends determined to establish a school, designed to
meet the demands of rich and of poor,[147] which does not seem at
all strange since they were known to have been supporting their poor
and the orphans by subscriptions since their first establishment.[148]
The transaction of the business relating thereto was performed in the
monthly meeting and referred to the quarterly meeting (higher) for its
approval. The following extract from the records of the meeting gives
the result of their decision:

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DERMOSCOPY: THE ESSENTIALS, THIRD EDITION  ISBN: 978-0-7020-6882-9

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

KEY TO TRAFFIC LIGHT SYMBOLS

High risk lesions

Moderate risk lesions

Low risk lesions

To my teacher in dermoscopy and to my friends in

H. Peter Soyer, MD, FACD

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Fig. 7 Seborrheic keratosis.

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Fig. 15 Basal cell carcinoma.

Introduction: The 3-point checklist

Fig. 17 Basal cell carcinoma.

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Fig. 26 Basal cell carcinoma.

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Fig. 34 Basal cell carcinoma.

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Fig. 44 Seborrheic keratosis.

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Introduction: The 3-point checklist

Fig. 57 Basal cell carcinoma.

The checklist score for this lesion is zero.

Fig. 60 Basal cell carcinoma.

Dermoscopic criteria for specific diagnoses

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

Four global patterns

This bit of philosophy is educational in its bearing in very much the

Rather have an ingenious person in the house to teach

The above quotation alone would seem to be adequate proof that

If, as must be admitted, the previous statement [Sidenote: His

Another character of very great importance in [Sidenote:

I do not know how it is amongst you, but here any person of

He endeavors to show that the work of a teacher is pleasant and

regarded education as a social duty, both to each parents]

Meditating on the situation of schools in our provinces, my

If to this list of advocates of education, it is [Sidenote: Tuke,

They acknowledge the understanding of languages,

Moreover, from various sources one is assured [Sidenote: The

It would be quite improper in connection with this [Sidenote:

inhabiting the said provinces, do put their

2. That schools be provided in all towns and [Sidenote: To

3. That the scholars be kept in the morning [Sidenote: Eight

4. The seventh day of the week the scholars [Sidenote:

5. Let the like meetings be kept by the school [Sidenote: Similar

rich people, let them be maintained free of

DERMOSCOPY: THE ESSENTIALS, THIRD EDITION ISBN: 978-0-7020-6882-9