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PDF Uptodate Dermatology 2020 Edition Uptodate Ebook Full Chapter
PDF Uptodate Dermatology 2020 Edition Uptodate Ebook Full Chapter
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Contents
Cover 1
Overview of dermoscopy 2
Dermoscopic evaluation of skin lesions 11
Dermoscopy of pigmented lesions of the palms and soles 25
Patch testing 83
Evaluation and diagnosis of hair loss 91
Approach to the clinical dermatologic diagnosis 109
Approach to the patient with a scalp disorder 198
Approach to the patient with an intertriginous skin disorder 210
Approach to the patient with annular skin lesions 222
Approach to the patient with cutaneous blisters 235
Approach to the patient with facial erythema 342
Approach to the patient with pustular skin lesions 387
Approach to the patient with retiform (angulated) purpura 446
Approach to the differential diagnosis of leg ulcers 458
Evaluation of adults with cutaneous lesions of vasculitis 471
Office-based dermatologic diagnostic procedures 483
Longitudinal melanonychia 492
Erythroderma in adults 503
Acquired hyperpigmentation disorders 518
Overview of nail disorders 542
Atopic dermatitis 566
allergic contact dermatitis 650
Contact dermatitis in children 677
Irritant contact dermatitis in adults 688
Chronic hand eczema 705
Patch testing 717
Management of allergic contact dermatitis 725
Poison ivy (Toxicodendron) dermatitis 733
Eyelid dermatitis (eczema) 743
Keratosis pilaris 753
Keratosis pilaris atrophicans 758
Cheilitis 763
Acute palmoplantar eczema (dyshidrotic eczema) 774
Cradle cap and seborrheic dermatitis in infants 784
Intertrigo 790
Nummular eczema 798
Overview of dermatitis (eczema) 804
Prurigo nodularis 901
Seborrheic dermatitis in adolescents and adults 912
Stasis dermatitis 925
Vulvar dermatitis 937
Urticarial dermatitis 951
Radiation dermatitis 970
Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris 988
Postadolescent acne in women 1007
Treatment of acne vulgaris 1017
Oral isotretinoin therapy for acne vulgaris 1046
Hormonal therapy for women with acne vulgaris 1060
Light-based, adjunctive, and other therapies for acne vulgaris 1072
Perioral (periorificial) dermatitis 1080
Rosacea Pathogenesis, clinical features, and diagnosis 1092
Management of rosacea 1105
PsoriasisEpidemiology, clinical manifestations, and diagnosis 1124
Pathophysiology of plaque psoriasis 1196
Nail psoriasis 1208
Guttate psoriasis 1245
Treatment of psoriasis in adults 1274
Erythrodermic psoriasis in adults 1318
Treatment selection for moderate to severe plaque psoriasis in special 1343
Psoriasis in children epidemiology clinical manifestation and dianosis 1366
Psoriasis in childrenManagement of chronic plaque psoriasis 1400
Management of psoriasis in pregnancy 1426
Comorbid disease in psoriasis 1444
Patient education Psoriasis (Beyond the Basics) 1463
Pustular psoriasisPathogenesis, clinical manifestations, and diagnosis 1482
Pustular psoriasisManagement 1509
Palmoplantar pustulosisEpidemiology, clinical features, and diagnosis 1531
Palmoplantar pustulosis Treatment 1561
Lichen planus 1583
Lichen Planopilaris 1597
Vulvar lichen planus 1614
Oral lichen planusPathogenesis, clinical features, and diagnosis 1631
Oral lichen planus Management and prognosis 1640
Pityriasis rosea 1651
Pityriasis lichenoides chronica 1683
Pityriasis lichenoides et varioliformis acuta (PLEVA) 1707
Pityriasis rubra pilaris 1739
Confluent and reticulated papillomatosis 1771
Lichen striatus 1799
New-onset urticaria 1827
Chronic spontaneous urticariaClinical manifestations, diagnosis,and natural 1860
Chronic spontaneous urticariaStandard management and patient education 1893
Chronic spontaneous urticaria Treatment of refractory symptoms 1921
An overview of angioedemaPathogenesis and causes 1940
An overview of angioedemaClinical features, diagnosis, and management 1956
Hereditary angioedemaPathogenesis and diagnosis 1986
Hereditary angioedema Epidemiology, clinical manifestations, exacerbating
prognosis 2000
Hereditary angioedema (due to C1 inhibitor deficiency)General care andterm 2011
Hereditary angioedema with normal C1 inhibitor 2037
Hereditary angioedemaAcute treatment of angioedema attacks 2052
Hereditary angioedema Temporary prophylaxis before procedures or stress
angioedema episodes 2077
Acquired C1 inhibitor deficiencyClinical manifestations, epidemiology,and 2090
Acquired C1 inhibitor deficiencyManagement and prognosis 2101
ACE inhibitor-induced angioedema 2115
Physical (inducible) forms of urticaria 2129
Cold urticaria 2167
Urticarial vasculitis 2188
Pathogenesis, clinical manifestations, and diagnosis of pemphigus 2221
Paraneoplastic pemphigus 2236
Initial management of pemphigus vulgaris and pemphigus foliaceus 2249
Management of refractory pemphigus vulgaris and pemphigus foliaceus 2264
Fogo selvagem Brazilian endemic pemphigus foliaceus 2275
Epidemiology and pathogenesis of bullous pemphigoid and mucous
2288
Clinical features and diagnosis of bullous pemphigoid and mucous
2298
Ocular cicatricial pemphigoid 2315
Management and prognosis of bullous pemphigoid 2330
Management of mucous membrane pemphigoid 2345
Dermatitis herpetiformis 2356
Epidermolysis bullosa acquisita 2369
Friction blisters 2383
Linear IgA bullous dermatosis 2390
Evaluation and diagnosis of hair loss 2404
Overview of dermoscopy of the hair and scalp 2422
Alopecia areataClinical manifestations and diagnosis 2435
Alopecia areataManagement 2445
Androgenetic alopecia in menPathogenesis, clinical features, and diagnosis 2460
Treatment of androgenetic alopecia in men 2470
Female pattern hair loss (androgenetic alopecia in women) Pathogenesis,
and diagnosis 2480
Female pattern hair loss (androgenetic alopecia in women)Treatment and 2490
Telogen effluvium 2498
Traction alopecia 2511
Lichen planopilaris 2523
Acne keloidalis nuchae 2540
Central centrifugal cicatricial alopecia 2556
Dissecting cellulitis of the scalp 2571
Erosive pustular dermatosis of the scalp 2580
Folliculitis decalvans 2590
Hair shaft disorders 2605
Pseudofolliculitis barbae 2615
Overview of nail disorders 2625
Overview of dermoscopy 2740
Dermoscopic evaluation of skin lesions 2749
Dermoscopy of facial lesions 2763
Dermoscopy of pigmented lesions of the palms and soles 2826
Dermoscopy of nail pigmentations 2882
Dermoscopy of nonpigmented nail lesions 2920
Dermoscopic algorithms for skin cancer triage 2952
Dermoscopy of mucosal lesions 2988
MelasmaEpidemiology, pathogenesis, clinical presentation, and diagnosis 3009
MelasmaManagement 3020
Acquired melanocytic nevi (moles) 3037
Benign pigmented skin lesions other than melanocytic nevi (moles) 3047
Atypical (dysplastic) nevi 3056
Spitz nevus and atypical Spitz tumors 3071
Congenital melanocytic nevi 3090
Congenital and inherited hyperpigmentation disorders 3100
VitiligoPathogenesis, clinical features, and diagnosis 3116
VitiligoManagement and prognosis 3129
Acquired hypopigmentation disorders other than vitiligo 3145
Lentigo maligna Clinical manifestations, diagnosis, and management 3158
Melanoma Clinical features and diagnosis 3172
Risk factors for the development of melanoma 3190
Screening and early detection of melanoma in adults and adolescents 3207
Melanoma in children 3227
Epidemiology and risk factors for skin cancer in solid organ transplant 3242
Pathologic characteristics of melanoma 3254
Pathologic evaluation of regional lymph nodes in melanoma 3268
Tumor, node, metastasis (TNM) staging system and other prognostic factors
melanoma 3274
Surgical management of primary cutaneous melanoma or melanoma at
sites 3286
Staging work-up and surveillance after treatment of melanoma 3300
Primary prevention of melanoma 3310
Prevention and management of skin cancer in solid organ transplant 3323
Cellulitis and skin abscessClinical manifestations and diagnosis 3340
Cellulitis and skin abscess in adultsTreatment 3351
Erythrasma 3364
Impetigo 3371
Pitted keratolysis 3379
Pseudomonas aeruginosa skin and soft tissue infections 3388
Cutaneous manifestations of tuberculosis 3401
Cutaneous manifestations of gonorrhea 3418
Staphylococcal scalded skin syndrome 3425
Necrotizing soft tissue infections 3438
Trichomycosis (trichobacteriosis) 3454
Botryomycosis 3460
Yaws, bejel, and pinta 3467
Pediculosis capitis 3486
Pediculosis corporis 3500
Pediculosis pubis and pediculosis ciliaris 3516
ScabiesEpidemiology, clinical features, and diagnosis 3524
Scabies Management 3533
Bedbugs 3542
Chigger bites 3552
Jellyfish stings 3557
Lepidopterism Skin disorders secondary to caterpillars and moths 3572
Dermatophyte (tinea) infections 3580
Tinea versicolor (pityriasis versicolor) 3593
Tinea capitis 3602
Tinea nigra 3619
OnychomycosisEpidemiology, clinical features, and diagnosis 3626
OnychomycosisManagement 3637
Candida infections in children 3653
Chromoblastomycosis 3667
Lobomycosis 3679
Piedra 3688
Cutaneous warts (common, plantar, and flat warts) 3695
Condylomata acuminata (anogenital warts) in adults Epidemiology,clinicaland 3710
Condylomata acuminata (anogenital warts) Management of external
in men 3719
Condylomata acuminata (anogenital warts) in children 3734
Epidemiology, clinical manifestations, and diagnosis of genital herpesvirus 3743
Treatment of genital herpes simplex virus infection 3758
Prevention of genital herpes virus infections 3772
Treatment of herpes simplex virus type 1 infection in immunocompeten 3782
Epidemiology, clinical manifestations, and diagnosis of herpes zoster 3792
Treatment of herpes zoster in the immunocompetent host 3807
Molluscum contagiosum 3817
Orf virus infection 3833
HIV-associated eosinophilic folliculitis 3839
Fever and rash in the immunocompetent patient 3849
Gianotti-Crosti syndrome (papular acrodermatitis) 3921
Clinical manifestations, diagnosis, and management of diabetic infections of
etremities 3929
Infectious folliculitis 3944
Soft tissue infections following water exposure 3958
Skin lesions in the returning traveler 3969
Drug eruptions 3978
Exanthematous (maculopapular) drug eruption 3989
Lichenoid drug eruption (drug-induced lichen planus 4000
Acute generalized exanthematous pustulosis (AGEP) 4012
Drug reaction with eosinophilia and systemic symptoms (DRESS) 4020
Fixed drug eruption 4037
Stevens-Johnson syndrome and toxic epidermal necrolysis 4047
Acneiform eruption secondary to epidermal growth factor receptor (EGFR)
inhibitors 4082
Cutaneous side effects of conventional chemotherapy agents 4096
Hand-foot skin reaction induced by multitargeted tyrosine kinase inhibitors 4118
Cutaneous adverse events of molecularly targeted therapy and otheragents
cancer therapy 4128
Epidemiology, natural history, and diagnosis of actinic keratosis 4142
Treatment of actinic keratosis 4152
Actinic cheilitis 4167
Epidemiology, pathogenesis, and clinical features of basal cell carcinoma 4174
Treatment and prognosis of basal cell carcinoma at low risk of recurrence 4191
Treatment of basal cell carcinomas at high risk for recurrence 4208
Evaluation for locoregional and distant metastases in cutaneous squamous
basal cell carcinoma 4218
Systemic treatment of advanced cutaneous squamous and basal cell 4227
Nevoid basal cell carcinoma syndrome (Gorlin syndrome) 4237
Cutaneous adnexal tumors 4253
Microcystic adnexal carcinoma 4347
Epidemiology and risk factors for cutaneous squamous cell carcinoma 4357
Cutaneous squamous cell carcinoma (cSCC) Clinical features and diagnosis 4372
Treatment and prognosis of low-risk cutaneous squamous cell carcinoma 4380
Recognition and management of high-risk (aggressive) cutaneous squamous
4397
Evaluation for locoregional and distant metastases in cutaneous squamous
basal cell carcinoma 4416
Systemic treatment of advanced cutaneous squamous and basal cell 4425
Keratoacanthoma 4435
Merkel cell (neuroendocrine) carcinoma 4455
Epidemiology and risk factors for skin cancer in solid organ transplant 4486
Prevention and management of skin cancer in solid organ transplant 4498
Sebaceous carcinoma 4515
Atypical fibroxanthoma 4524
Porokeratosis 4532
Overview of cutaneous lupus erythematosus 4548
Initial management of discoid lupus and subacute cutaneous lupus 4599
Management of refractory discoid lupus and subacute cutaneous lupus 4621
Tumid lupus erythematosus 4642
Bullous systemic lupus erythematosus 4672
Cutaneous dermatomyositis in adultsOverview and initial management 4694
Initial treatment of dermatomyositis and polymyositis in adults 4725
Management of refractory cutaneous dermatomyositis in adults 4745
Treatment of recurrent and resistant dermatomyositis and polymyositis in 4762
Malignancy in dermatomyositis and polymyositis 4775
Juvenile dermatomyositis and polymyositis Epidemiology, pathogenesis, and
4784
Juvenile dermatomyositis and polymyositis Diagnosis 4797
Juvenile dermatomyositis and polymyositisTreatment, complications, and 4815
Clinical manifestations, pathologic features, and diagnosis of Langerhans
4833
Treatment of Langerhans cell histiocytosis 4865
Necrobiotic xanthogranuloma 4887
Juvenile xanthogranuloma (JXG) 4907
Pathology and pathogenesis of sarcoidosis 4933
Cutaneous manifestations of sarcoidosis 4953
Clinical manifestations and diagnosis of pulmonary sarcoidosis 4999
Cutaneous sarcoidosisManagement 5039
Pathogenesis of systemic sclerosis (scleroderma) 5065
Risk factors for and possible causes of systemic sclerosis (scleroderma) 5089
Clinical manifestations and diagnosis of systemic sclerosis (scleroderma) in 5098
Pretreatment evaluation of adults with systemic sclerosis (scleroderma) 5132
Overview of the treatment and prognosis of systemic sclerosis (scleroderma)
5141
Juvenile systemic sclerosis (scleroderma)Classification, clinicaland diagnosis 5158
Juvenile systemic sclerosis (scleroderma)Assessment and approaches to 5181
Pathogenesis, clinical manifestations, and diagnosis of morphea (localizedin 5203
Treatment of morphea (localized scleroderma) in adults 5238
Localized scleroderma in childhood 5248
Scleredema 5291
Scleromyxedema 5312
Nephrogenic systemic fibrosis-nephrogenic fibrosing dermopathy inkidney 5340
Evaluation of adults with cutaneous lesions of vasculitis 5367
Overview of cutaneous small vessel vasculitis 5400
Management of adults with idiopathic cutaneous small vessel vasculitis 5407
Urticarial vasculitis 5420
Livedoid vasculopathy 5453
IgA vasculitis (Henoch-Schönlein purpura)Clinical manifestations and 5472
IgA vasculitis (Henoch-Schönlein purpura)Management 5496
Erythema induratum (nodular vasculitis) 5505
Erythema elevatum diutinum 5523
Acanthosis nigricans 5545
Anetoderma 5578
Cutaneous polyarteritis nodosa 5596
Cutaneous xanthomas 5615
Erythema annulare centrifugum 5658
Erythema nodosum 5689
Erythromelalgia 5713
Localized lichen myxedematosus 5729
Palisaded neutrophilic and granulomatous dermatitis 5746
Necrobiosis lipoidica 5759
Panniculitis Recognition and diagnosis 5791
Pathogenesis of Raynaud phenomenon 5826
Perforating dermatoses 5837
Pernio (chilblains) 5878
Pigmented purpuric dermatoses (capillaritis) 5896
Calcinosis cutis Etiology and patient evaluation 5942
Calcinosis cutisManagement 5984
Neutrophilic dermatoses 5991
Pyoderma gangrenosum Pathogenesis, clinical features, and diagnosis 6055
Pyoderma gangrenosum Treatment and prognosis 6082
Sweet syndrome 6098
Cutaneous manifestations of amyloidosis 6138
Cutaneous manifestations of graft-versus-host disease (GVHD) 6181
Cutaneous manifestations of internal malignancy 6241
Parapsoriasis (small plaque and large plaque parapsoriasis) 6306
Classification of primary cutaneous lymphomas 6316
Approach to the patient with a diagnosis of atypical lymphocytic infiltrate of
6324
Variants of mycosis fungoides 6332
Primary cutaneous T cell lymphomas, rare subtypes 6346
Clinical manifestations, pathologic features, and diagnosis of peripheral T
not otherwise specified 6358
Treatment of early stage (IA to IIA) mycosis fungoides 6367
Treatment of advanced stage (IIB to IV) mycosis fungoides 6382
Treatment of Sézary syndrome 6402
Primary cutaneous anaplastic large cell lymphoma 6423
Clinical manifestations, pathologic features, and diagnosis of systemiclarge
6435
Jessner's lymphocytic infiltrate 6448
Cutaneous B cell pseudolymphomas 6453
Cutaneous T cell pseudolymphomas 6460
Eosinophilic cellulitis (Wells syndrome) 6470
Lymphomatoid papulosis 6480
Primary cutaneous follicle center lymphoma 6498
Primary cutaneous large B cell lymphoma, leg type 6509
Primary cutaneous marginal zone lymphoma 6518
Angiolymphoid hyperplasia with eosinophilia and Kimura disease 6531
Overview of benign lesions of the skin 6542
PruritusEtiology and patient evaluation 6561
Pruritus Overview of management 6577
Oral lesions 6589
Recurrent aphthous stomatitis 6612
Oral lichen planus Pathogenesis, clinical features, and diagnosis 6626
Oral lichen planusManagement and prognosis 6635
Oral leukoplakia 6646
Vulvar dermatitis 6653
Vulvar lichen sclerosus 6667
Extragenital lichen sclerosus 6686
Primary focal hyperhidrosis 6697
Bromhidrosis 6713
Chromhidrosis 6721
Fox-Fordyce disease (apocrine miliaria) 6728
Miliaria 6737
Granular parakeratosis 6746
Granuloma annulare 6754
Granuloma faciale 6771
Dermatoses of pregnancy 6781
Erythema multiformePathogenesis, clinical features, and diagnosis 6796
Erythema multiforme Management 6807
Grover's disease (transient and persistent acantholytic dermatosis) 6817
Hidradenitis suppurativaPathogenesis, clinical features, and diagnosis 6822
Hidradenitis suppurativa Treatment 6835
Surgical management of hidradenitis suppurativa 6854
Keloids and hypertrophic scars 6864
Laser therapy for hypertrophic scars and keloids 6878
Mastocytosis (cutaneous and systemic)Epidemiology, pathogenesis, and
6892
Mastocytosis (cutaneous and systemic)Evaluation and diagnosis in children 6906
Mastocytosis (cutaneous and systemic)Evaluation and diagnosis in adults 6918
Treatment and prognosis of cutaneous mastocytosis 6936
Systemic mastocytosisDetermining the subtype of disease 6946
Indolent and smoldering systemic mastocytosis Management and prognosis 6957
Advanced systemic mastocytosisManagement and prognosis 6971
Cutaneous manifestations of amyloidosis 6989
Necrobiosis lipoidica 7001
Atrophoderma of Pasini and Pierini 7015
Paronychia 7022
Pernio (chilblains) 7032
Skin picking (excoriation) disorder and related disorders 7041
Skin biopsy techniques 7058
Subcorneal pustular dermatosis 7073
Technique of incision and drainage for skin abscess 7084
Management of ingrown toenails 7101
Office-based dermatologic diagnostic procedures 7115
Intralesional corticosteroid injection 7124
Topical corticosteroidsUse and adverse effects 7131
Pyogenic granuloma (lobular capillary hemangioma) 7143
Acute genital ulceration (Lipschutz ulcer) 7191
Vesicular, pustular, and bullous lesions in the newborn and infant 7209
Aplasia cutis congenita 7283
Approach to the patient with a scalp disorder 7306
Approach to the patient with pustular skin lesions 7395
Atypical exanthems in children 7457
Candida infections in children 7486
Capillary malformations (port wine stains) and associated syndromes 7521
Condylomata acuminata (anogenital warts) in children 7553
Contact dermatitis in children 7572
Cradle cap and seborrheic dermatitis in infants 7600
Cutaneous developmental anomalies in the newborn and infant 7627
Diaper dermatitis 7656
Epidermal nevus and epidermal nevus syndrome 7702
Evaluation of purpura in children 7734
Gianotti-Crosti syndrome (papular acrodermatitis) 7769
IgA vasculitis (Henoch-Schonlein purpura)Clinical manifestations and 7796
IgA vasculitis (Henoch-Schonlein purpura)Management 7820
Infantile hemangiomasEpidemiology, pathogenesis, clinical features, and 7829
Infantile hemangiomasEvaluation and diagnosis 7858
Infantile hemangiomasManagement 7879
Juvenile dermatomyositis and polymyositisEpidemiology, pathogenesis, and
7907
Juvenile dermatomyositis and polymyositisDiagnosis 7920
Juvenile dermatomyositis and polymyositisTreatment, complications, and 7938
Juvenile systemic sclerosis (scleroderma)Classification, clinicaland diagnosis 7956
Juvenile systemic sclerosis (scleroderma)Assessment and approaches to 7979
Juvenile xanthogranuloma (JXG) 8001
Klippel-Trenaunay syndromeClinical manifestations, diagnosis, and 8027
Localized scleroderma in childhood 8049
Melanoma in children 8092
Mycoplasma pneumoniae-induced rash and mucositis (MIRM) 8120
Neonatal and infantile erythroderma 8146
Nevus sebaceus and nevus sebaceus syndrome 8189
Overview of vulvovaginal complaints in the prepubertal child 8217
PHACE syndrome 8248
Rapidly involuting congenital hemangioma (RICH) and noninvoluting
NICH) 8265
Sclerema neonatorum 8290
Skin lesions in the newborn and infant 8301
Skin nodules in newborns and infants 8338
Sturge-Weber syndrome 8371
Subcutaneous fat necrosis of the newborn 8387
Tufted angioma, kaposiform hemangioendothelioma, and the Kasabach-
8397
Vascular lesions in the newborn 8424
Vasculitis in children Evaluation overview 8458
Venous malformations 8488
Overview of cutaneous photosensitivityPhotobiology, patient evaluation, and 8513
Photosensitivity disorders (photodermatoses)Clinical manifestations,and 8522
Polymorphous light eruption 8552
PorphyriasAn overview 8571
Porphyria cutanea tarda and hepatoerythropoietic porphyriaPathogenesis,
and diagnosis 8598
Porphyria cutanea tarda and hepatoerythropoietic porphyria Management
8618
Congenital erythropoietic porphyria 8630
Variegate porphyria 8646
Erythropoietic protoporphyria and X-linked protoporphyria 8666
Hereditary coproporphyria 8687
Pseudoporphyria 8712
Sunburn 8741
Selection of sunscreen and sun-protective measures 8778
Targeted phototherapy 8794
UVB therapy (broadband and narrowband) 8804
UVA1 phototherapy 8822
Psoralen plus ultraviolet A (PUVA) photochemotherapy 8829
The genodermatoses An overview 8851
Epidemiology, pathogenesis, classification, and clinical features ofbullosa 8863
Diagnosis of epidermolysis bullosa 8882
Overview of the management of epidermolysis bullosa 8892
Overview and classification of the inherited ichthyoses 8910
Ichthyosis vulgaris 8921
Autosomal recessive congenital ichthyosis 8929
Recessive X-linked ichthyosis 8941
The dyschromatoses 8952
Birt-Hogg-Dube syndrome 8960
Brooke-Spiegler syndrome (CYLD cutaneous syndrome) 8971
Buschke-Ollendorff syndrome 8980
Carney complex 8990
Cutaneous leiomyomatosis 8999
Cutis verticis gyrata 9007
Darier disease 9013
Ectodermal dysplasias 9025
Epidermodysplasia verruciformis 9062
Focal dermal hypoplasia (Goltz syndrome) 9070
Hailey-Hailey disease (benign familial pemphigus) 9077
Hereditary palmoplantar keratodermas 9087
Hermansky-Pudlak syndrome 9106
Hutchinson-Gilford progeria syndrome 9114
Incontinentia pigmenti 9122
Keratinopathic ichthyoses 9132
Kindler syndrome 9140
Lipoid proteinosis 9150
Muir-Torre syndrome 9159
Netherton syndrome 9165
Nevoid basal cell carcinoma syndrome (Gorlin syndrome) 9177
Oculocutaneous albinism 9193
Pachyonychia congenita 9208
Peeling skin syndromes 9217
Piebaldism 9228
Pigmentary mosaicism (hypomelanosis of Ito) 9237
Tumor protein p63-related disorders 9248
Xeroderma pigmentosum 9254
Skin biopsy techniques 9267
Fusiform - elliptical excision - UpToDate.pdf (p.16-24) 9282
Minor dermatologic procedures 9291
Skin surgeryPrevention and treatment of complications 9307
Mohs surgery 9318
Anatomic danger zones in cutaneous surgery of the head and neck 9332
Nail biopsy Indications and techniques 9341
Principles and overview of nail surgery 9348
Nail avulsion and chemical matricectomy 9362
Overview of botulinum toxin for cosmetic indications 9371
Botulinum toxin for cosmetic indications Treatment of specific sites 9386
Injectable soft tissue fillersOverview of clinical use 9398
Injectable soft tissue fillers Permanent agents 9409
Injectable soft tissue fillersTemporary agents 9417
Anatomic danger zones for facial injection of soft tissue fillers 9428
Chemical peels Principles 9438
Chemical peels Procedures and complications 9446
Principles of laser and intense pulsed light for cutaneous lesions 9459
Laser and light therapy for cutaneous hyperpigmentation 9470
Laser and light therapy for cutaneous vascular lesions 9485
Ablative laser resurfacing 9503
Nonablative skin resurfacing 9518
Photodynamic therapy 9533
Laser therapy of lower extremity telangiectasias, reticular veins, and small
9547
sclerotherapy techniques for lower extremity veins 9555
Topical skin-lightening agents Complications associated with misuse 9573
Management of acne scars 9580
Photoaging 9598
Postinflammatory hyperpigmentation 9611
Removal of unwanted hair 9623
Striae distensae (stretch marks) 9631
Tattoo removal 9647
What's new in dermatology 9657
Overview of dermoscopy - UpToDate
uptodate.com/contents/overview-of-dermoscopy/print
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2020. | This topic last updated: Sep 09, 2019.
Dermoscopy is performed with a handheld instrument called a dermatoscope. The procedure allows
for the visualization of subsurface skin structures in the epidermis, at the dermoepidermal junction,
and in the upper dermis; these structures are usually not visible to the naked eye [2-4]. The
dermoscopic images may be photographed or recorded digitally for storage or sequential analysis.
The basic principles of dermoscopy will be discussed in this topic. The dermoscopic diagnosis of
skin lesions, including those in special anatomic areas (eg, face, volar surfaces of palms and soles,
mucosal surfaces, and glabrous skin in genital area), dermoscopy of nail pigmentation, and
algorithms used for skin cancer triage are discussed separately.
2
DERMOSCOPY PHYSICS Ambient light is reflected,
scattered, or absorbed by objects. Under normal conditions, most of the light is reflected by the skin
surface because of the higher refractive index (RI) of the stratum corneum (1.55) compared with that
of the air (1.0).
Reduction of skin surface reflection allows for the visualization of deeper epidermal and dermal
structures. This reduction can be achieved by affixing a glass plate (RI: 1.52) to the stratum corneum
(RI: 1.55) and using an RI-matched immersion fluid as an interface or by using polarizing filters [5-7].
Several immersion fluids have been used, including water, alcohols (ethanol and isopropanol), oils
(mineral oil, immersion oil, and olive oil), and water-soluble gels (ultrasound gel, cosmetic gels).
Alcohols (in particular ethanol 70%) are the preferred immersion liquid due to their low viscosity,
amphiphilic properties (ie, both water and lipid soluble), disinfectant capabilities, and image clarity.
However, on some specific sites such as the mucosae and areas around the eyes and nails, water-
soluble gels are preferred over alcohol since they are noncaustic and have higher viscosity [6].
Alternatively, reduction of the skin surface reflection can be achieved by using polarized light [8].
Polarized light dermoscopy utilizes two orthogonally placed filters in a process called cross-
polarization (figure 1). After reaching the skin surface, part of the polarized light is reflected by the
stratum corneum maintaining its polarization, whereas part enters the skin and is scattered back
from the deeper layers, losing its polarization. The light reflected by the skin surface, responsible for
the glare of the skin, is blocked by the cross-polarized filter, since this light maintains its polarization.
The backscattered light from the deeper layers passes through the cross-polarized filter since some
of the polarized light has lost its angle of polarization. This makes the subsurface structures visible
to the eye [7-9].
3
shiny, white structures (shiny, white lines; shiny, white blotches; and strands and rosettes) are better
visualized with polarized light dermoscopy [5,7,11]. Structures visible in one mode and not in the
other will blink when viewed with dermatoscopes that can toggle between polarized and
nonpolarized light [12].
Colors — The colors seen with dermoscopy include yellow, red, brown, blue, gray, black, and
white (figure 2D) [18,19]. Melanin is the most important chromophore in pigmented lesions. The
color of melanin as seen on the surface of the skin depends upon its concentration and its
localization in the skin; it usually appears black if located in the stratum corneum, brown if in the
epidermis and superficial dermis, and gray/blue to blue if in the dermis. The color red is determined
by vascularity; a thrombus will appear black. White color is associated with collagen/fibrosis, and
yellow is associated with keratin or sebum.
Structures — The structures visualized in skin lesions are determined by the distribution
and amount of melanin, keratin, collagen, and vascularity [10,13,18,20-22].
●Pigment network, negative network, angulated lines, streaks, aggregated or peripheral rim of
globules, and homogeneous blue pigmentation are the hallmark of melanocytic lesions (picture 1A-
C).
●Arborizing vessels, leaf-like structures, spoke wheel-like structures, concentric structures, large
blue/gray ovoid nests, multiple blue/gray nonaggregated globules, shiny white blotches and strands,
ulceration, and multiple erosions are features of basal cell carcinomas (BCCs) (picture 2).
●Glomerular vessels, white circles, rosettes, white/yellow scale, brown circles, and brown
dots/globules aligned radially are structures of squamous cell carcinomas (picture 3).
●Milia-like cysts, comedo-like openings, finger print-like structures, moth-eaten borders, gyri and
sulci, and sharp demarcation are characteristic of seborrheic keratoses (picture 4).
Red or blue/purple/black lagoons are seen in cherry angiomas or angiokeratomas (picture 5). (See
"Dermoscopic evaluation of skin lesions", section on 'First step: Melanocytic versus
nonmelanocytic'.)
●Atypical pigment network, blue-white veil, atypical vascular pattern, irregular streaks, atypical dots
or globules, angulated lines creating a zigzag pattern or polygons, and regression structures are
some of the features associated with melanoma (picture 6A-C). (See "Dermoscopic evaluation of
skin lesions", section on 'Second step: Nevus versus suspicious lesion or melanoma'.)
4
A detailed description of the dermoscopic structures visualized in melanocytic and nonmelanocytic
lesions and their histologic correlates is provided in the figures (figure 2A-C).
The diagnostic criteria for benign and malignant melanocytic and nonmelanocytic skin lesions are
discussed separately. (See "Dermoscopic evaluation of skin lesions".)
Noncontact polarized light is the preferred type of dermatoscope for the visualization of blood
vessels. However, if a contact dermatoscope is utilized, an ultrasound gel should be used as a liquid
interface since the gel acts as a cushion and reduces the need for pressure being applied to the skin,
preventing the blanching of the vessels.
Although some vessel morphologies are most commonly associated with certain types of lesions
(eg, arborizing vessels are common in BCC), the presence of a given vessel morphology is not
exclusive to a particular diagnosis. For example, dotted vessels can be seen in melanocytic tumors,
squamous cell carcinoma (picture 3), BCC, porokeratosis, clear cell acanthoma, and psoriasis
[25,28,29,31,32]. Similarly, glomerular vessels are most commonly associated with squamous cell
carcinoma/Bowen disease (picture 3), but they can also be seen in clear cell acanthoma.
Polymorphous vessels are typically associated with melanoma but can also be seen in BCC [28].
Arborizing vessels are commonly seen in BCC, but they can also be seen in melanoma and
intradermal nevi. Hairpin vessels are commonly associated with seborrheic keratoses, although they
can also be seen in melanoma. Despite this overlap, the positive predictive value for a given vessel
morphology can guide the clinician to the correct diagnosis if the clinical context is carefully
considered (table 2A-B). (See "Dermoscopic evaluation of skin lesions", section on 'Second step:
Nevus versus suspicious lesion or melanoma'.)
5
Dermoscopy requires some formal training to be effectively practiced. Online tutorials on
dermoscopy can be found at www.dermnetnz.org/doctors/dermoscopy-course/introduction.html,
www.dermoscopy-ids.org/index.php/education/podcasts, www.genomel.org/dermoscopy, or
www.dermoscopedia.org.
Cross-sectional studies, randomized trials, meta-analyses, and a 2018 Cochrane systematic review
have indicated that dermoscopic examination has a higher discriminatory power than naked-eye
examination to detect skin cancer, including melanoma either in experimental or real-life clinical
settings [13,33,35-43]. For clinicians with at least minimal training in dermoscopy, the addition of this
procedure to the clinical examination increases the accuracy of the in vivo diagnosis of skin cancer
and reduces the number of unnecessary biopsies [36] (see "Evaluating diagnostic tests"). In fact, 86
percent of dermoscopy users from 32 European countries reported that dermoscopy increased their
melanoma detection rate, and 70 percent reported that dermoscopy decreased the number of
unnecessary biopsies of benign lesions they performed [44].
In a systematic review of 27 studies performed in clinical and experimental settings, the diagnostic
accuracy of dermoscopy was lower for inexperienced examiners compared with experts, and was
inversely proportional to the prevalence of melanoma in the sample [39]. The degree of experience
improved the diagnostic accuracy of complex algorithms, such as pattern analysis, whereas it did
not affect the performance of simpler algorithms such as the ABCD rule of dermoscopy.
6
Two clinical trials performed in primary care settings have shown that a short training in
dermoscopy enables nondermatologists to use simplified diagnostic algorithms and improve their
accuracy in the diagnosis of melanoma [36,47]. In one trial, 73 primary care physicians received one-
day training in skin cancer detection and dermoscopy and were subsequently randomly assigned to
use a polarized light handheld dermatoscope or the naked eye to assess the pigmented lesions of
their patients for a period of 16-months [36]. All patients were also independently evaluated by
expert dermatologists. The sensitivity for the referral of suspicious lesions was significantly higher
in the dermoscopy group, compared with the naked-eye examination group (79 and 54 percent,
respectively), without difference in specificity (71 and 72 percent, respectively).
A 2019 systematic review of 23 randomized and observational studies performed in primary care
settings confirmed that dermoscopy, with appropriate training, was associated with improved
diagnostic accuracy for melanoma and benign lesions and reduced unnecessary excisions and
referrals [48]. However, the minimal amount of training required to achieve competence in
dermoscopy has not been determined.
Although it will be beneficial to examine as many lesions as possible in patients with multiple nevi,
special attention should be paid to the following [50]:
●Any lesions that are a concern (including symptomatically) for the patient
●Outlier skin lesions that are clinically different from the other lesions (the "ugly duckling" sign)
In addition, dermoscopy has been shown to be a useful tool in the evaluation of other dermatologic
entities, such as inflammatory and infectious diseases and hair and nail disorders. (See
"Dermoscopy of nail pigmentations" and "Dermoscopy of nonpigmented nail lesions".)
Purposes — Dermoscopy may have different purposes depending upon the clinical
setting in which it is used.
In general dermatology and in primary care practices, the primary purpose of dermoscopy is the
evaluation of pigmented and nonpigmented skin lesions to decide whether or not a lesion should be
biopsied or referred. For this purpose, a minimal amount of training is needed [36,51-53].
7
In specialized dermatologic settings, which include management of high-risk patients (eg, patients
with the dysplastic/atypical nevus syndrome), the main purposes of dermoscopy are to differentiate
early melanoma from benign skin lesions and to minimize the unnecessary excision of benign nevi.
Subtle signs of melanoma may be detected on dermoscopy by experienced clinicians before they
become clinically evident to the naked eye.
Digital dermoscopy may also be useful for long- or short-term follow-up of patients with multiple
common and atypical nevi [54-59]. Sequential digital dermoscopy imaging (SDDI) involves the
capture and comparison of sequential dermoscopic images of one or more melanocytic lesions for
short-term (three to four months) or long-term (6 to 12 months) surveillance. Several studies have
indicated that SDDI has high sensitivity and specificity for detecting in situ or thin invasive
melanomas that are difficult to diagnose otherwise [56-58,60]. One study showed that in the primary
care setting the combination of dermoscopy and short-term digital monitoring reduced the excision
or referral of benign pigmented skin lesions by 56 percent and increased the sensitivity for
diagnosing melanoma from 38 to 72 percent [53].
In addition to its conventional use, dermoscopy has also been shown to improve the clinical
diagnosis in other fields of dermatology, including infections/infestations as well as inflammatory
skin diseases and hair diseases [61].
Benefits
●Dermoscopy improves the diagnosis of melanocytic lesions in clinical practice. Several meta-
analyses of studies performed in experimental and clinical settings have indicated that dermoscopy
increases the sensitivity for the diagnosis of melanoma without decreasing the specificity, compared
with the naked-eye examination [33,37-39].
●Dermoscopy improves the confidence in the diagnosis of benign pigmented lesions, reducing the
number of unnecessary biopsies. In a randomized trial, dermatologists using dermoscopy,
compared with those using naked-eye examination, referred fewer patients for excision of benign
lesions (9 versus 16 percent) without missing malignant lesions [40]. Several retrospective studies
examined the numbers of excised benign and malignant lesions in dermatologic practices before
and after the introduction of dermoscopy [62,63]. In one study, the ratio between benign and
malignant excised lesions decreased from 18:1 to 4:1 over a three-year period [62].
●Dermoscopy allows digital surveillance and monitoring of melanocytic lesions in patients with
multiple common or atypical nevi [54-59].
●Dermoscopy is useful in the diagnosis and differentiation of nonmelanocytic benign and malignant
tumors such as basal cell carcinoma, dermatofibroma, seborrheic keratosis, and hemangioma
[10,21,25,27].
Limitations
8
●The diagnostic accuracy of dermoscopy may be poorer than naked-eye examination when
performed by individuals with limited experience in the interpretation of dermoscopy [39].
Dermoscopy requires at least a minimal amount of training to provide advantage over the clinical
examination [64]. The correct interpretation of dermoscopic images depends upon knowledge of the
significance of colors and structures manifested by a lesion. In addition, examining a lesion with
reference to the clinical context and comparison to surrounding lesions is also important for
rendering a correct diagnosis [45].
●Even in expert hands, dermoscopy may fail to recognize melanomas that lack specific dermoscopic
criteria (featureless melanomas) or melanomas masquerading as inflammatory or benign lesions,
such as Spitzoid melanomas, amelanotic melanomas, nodular melanomas, nevoid melanomas,
desmoplastic melanomas, or verrucous melanomas [65,66].
●Although digital dermoscopic images are suitable for distance consultation, interpretation of
dermoscopic photographs may be slightly less accurate than in-vivo dermoscopy [67,68].
SUMMARY AND
RECOMMENDATIONS
●Dermoscopy is a noninvasive, in vivo technique primarily used for the examination of skin lesions.
A handheld instrument called a dermatoscope, consisting of a light source and magnifying optics,
allows the visualization of subsurface skin structures that are usually not visible to the naked eye.
(See 'Dermoscopy physics' above and 'Types of dermatoscopes' above.)
●Colors and structures visualized in skin lesions are mainly related to the amount, distribution, and
localization of melanin, vasculature structures, collagen, and keratin (figure 2A-D and table 2A-B).
●Pigment network, negative network, angulated lines, streaks, aggregated globules or peripheral rim
of globules, and homogeneous, blue pigmentation are the hallmark of melanocytic lesions (picture
1A-C). Arborizing vessels, leaf-like structures, spoke wheel-like structures/concentric globules, ovoid
or round blue/gray nonaggregated areas, and shiny white blotches and strands are features of basal
cell carcinomas (picture 2). Glomerular vessels, white circles, rosettes, white/yellow scale crust,
brown circles, and brown dots/globules aligned radially are structures of squamous cell carcinomas.
Milia-like cysts, comedo-like openings, and gyri and sulci are characteristic of seborrheic keratoses
(picture 4), whereas red or blue/purple/black lagoons are seen in cherry angiomas or
angiokeratomas (picture 5). (See "Dermoscopic evaluation of skin lesions", section on 'First step:
Melanocytic versus nonmelanocytic'.)
9
●Atypical pigment network, negative network, atypical vascular pattern, irregular streaks, atypical
dots or globules, regression structures, blue-white veil, angulated lines forming a zigzag pattern or
polygons (such as rhomboids), and peripheral tan structureless areas are some of the features
associated with melanoma (picture 6A-C). (See "Dermoscopic evaluation of skin lesions", section on
'Second step: Nevus versus suspicious lesion or melanoma'.)
●For clinicians who have been formally trained, the addition of dermoscopy to clinical examination
improves the sensitivity and specificity of the in vivo diagnosis of skin cancer, including melanoma.
In particular, dermoscopy improves the confidence in the diagnosis of benign lesions and reduces
the number of unnecessary biopsies. However, even in expert hands, dermoscopy may fail to
recognize melanomas lacking specific dermoscopic features. (See 'Diagnostic accuracy for
melanoma' above and 'Benefits' above and 'Limitations' above.)
●Dermoscopy may be useful in patients with multiple common or atypical nevi who are at increased
risk for melanoma. Special attention should be paid to lesions with reported history of change and
lesions appearing clinically different from the other lesions (the "ugly duckling" sign) or clinically
suspicious of melanoma. (See 'Indications' above.)
10
Dermoscopic evaluation of skin lesions
uptodate.com/contents/dermoscopic-evaluation-of-skin-lesions/print
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2020. | This topic last updated: Sep 26, 2018.
Dermoscopic diagnosis involves the recognition of specific structures, or their absence, to rule out
or confirm a given diagnosis. From a cognitive perspective, this task may be accomplished using a
bottom-up or a top-down strategy. In the bottom-up approach, the observer performs a visual search
for salient details (individual features) to arrive at a diagnosis, whereas in the top-down strategy the
observer recognizes the general context, generates a hypothesis of the likely clinical diagnosis, and
performs a targeted dermoscopic search for specific features to confirm the presumed clinical
diagnosis [4].
This topic will review several algorithms and scoring systems that use mainly a top-down strategy to
help clinicians distinguish melanocytic lesions from nonmelanocytic lesions (First Step) and
differentiate nevus from melanoma or lesions suspicious for melanoma (Second Step). The general
principles of dermoscopy, dermoscopic structure terminology, dermoscopic evaluation of skin
lesions, and the dermoscopic evaluation of facial, mucosal, and acral volar skin lesions are
discussed separately. Dermoscopy of nail pigmentation and dermoscopic algorithms for skin cancer
triage are also discussed separately.
11
●(See "Dermoscopy of mucosal lesions".)
In the first step, the observer decides whether a lesion is melanocytic or nonmelanocytic by looking
for the presence or absence of specific features. In addition to differentiating melanocytic lesions
from nonmelanocytic lesions, the first step of the two-step algorithm also serves as an aid to
correctly sub-classify the nonmelanocytic lesions [5,6]. (See "Overview of dermoscopy".)
The second step is intended only for lesions classified as melanocytic. Melanocytic lesions are
further evaluated to differentiate nevi from suspicious lesions or melanoma by using one of several
algorithms created for this purpose [8-12]. (See 'Second step: Nevus versus suspicious lesion or
melanoma' below.)
The lesion is first examined for the presence of structures that are typical of melanocytic lesions. If
none of those structures are found, the lesion is examined for the presence of features of
dermatofibroma, basal cell carcinoma, squamous cell carcinoma, seborrheic keratosis, or
angioma/hemangioma/angiokeratoma.
Lesions lacking features to classify them as one of the aforementioned categories are evaluated for
the presence of blood vessels. The morphology, distribution, and arrangement of blood vessels can
assist in classifying these lesions into melanocytic or nonmelanocytic tumors.
12
Lesions lacking features that would allow their characterization as melanocytic or nonmelanocytic
lesions are classified as featureless (feature poor, nonspecific, nonclassifiable, or structureless)
lesions. Melanoma needs to be ruled out for all featureless lesions. (See 'Featureless lesions
(feature poor, nonspecific, nonclassifiable, or structureless)' below and 'Vascular structures in skin
lesions' below.)
●Pigment network
●Angulated lines
●Negative network
Lesions presenting with any of the above structures are classified as melanocytic and will proceed
to the second step to differentiate nevi from suspicious lesions or melanoma. (See 'Second step:
Nevus versus suspicious lesion or melanoma' below.)
13
●Arborizing vessels
●Leaf-like areas
●Shiny white blotches and strands (seen with polarized dermoscopy) [17]
Additional clues in BCC are the presence of multiple in-focus, fine brown to gray dots and fine short
superficial telangiectasia.
●Rosettes
●Yellow scale
●Brown dots/globules aligned in straight, radially oriented lines, usually located towards the
periphery
●Brown circles
●Comedo-like openings.
●Moth-eaten borders.
●Gyri and sulci (also known as fissures and ridges) creating a cerebriform pattern. At times, these
gyri and sulci can create a pattern resembling a network.
●Fingerprint-like structures.
14
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