color atlas of melanocytic lesions of the skin - h. soyer, et al., (springer, 2007)

H. P. Soyer, G. Argenziano, R. Hofmann-Wellenhof, R. H. Johr (Eds.)
Color Atlas of Melanocytic Lesions of the Skin
H. P. Soyer    G. Argenziano    R. Hofmann-Wellenhof    
R. H. Johr (Eds.)
With 366 Figures and 26 Tables
Color Atlas
of Melanocytic
Lesions
of the Skin
123
H. Peter Soyer, MD, FACD
Professor of Dermatology
School of Medicine
University of Queensland
Princess Alexandra Hospital
Australia
Giuseppe Argenziano, MD
Professor of Dermatology 
Department of Dermatology 
Second University of Naples 
Nuovo Policlinico – Edificio 13 
Via Pansini 5 
I-80131 Naples
Italy
Rainer Hofmann-Wellenhof, MD
Professor of Dermatology 
Department of Dermatology
Medical University Graz
Auenbruggerplatz 8
A-8036 Graz

Austria
Robert H. Johr, MD
Clinical Professor of Dermatology and Pediatrics
Director, Pigmented Lesion Clinic
University of Miami, School of Medicine
Miami, FL 33136
USA
Library of Congress Control Number: 2007924719
ISBN 978-3-540-35105-4  Springer Berlin Heidelberg New York
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Desk Editor: Ellen Blasig, Heidelberg, Germany
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This book is dedicated to the memory of
PAOLO CARLI
an outstanding scientist
and a special human being.
H. Peter Soyer and Giuseppe Argenziano
on behalf of all authors

Foreword
Melanocytic tumors of the skin deserve special
attention because of the following important
facts
■ Melanoma is frequent and early detection
is critical.
■ A correct interpretation is necessary
because the implications may be very
serious.
■ It is a dynamically developing field where
major progress has been made over the
past decade.
This atlas, written in a concise way, is a highly
useful presentation that focuses on the full spec-
trum of pigmented skin tumors. The prominent
features include classical clinical as well as his-
topathological criteria for diagnosis, illustra-
tions of excellent quality, as well as new concepts
and practical aspects of management. Of special
interest are modern diagnostic techniques with
emphasis on dermatoscopy. Case studies and
core messages indicating pathways of the diag-
nostic approach are at the end of each chapter.

All these features characterize the book as an
impressive contribution to the literature in the
area of melanocytic tumors.
My co-workers in Graz, Dr. H. Peter Soyer
and Dr. Rainer Hofmann-Wellenhof, as well as
Dr. Giuseppe Argenziano from Naples and Dr.
Robert Johr from Miami, together with many
international contributors who are all experts in
their respective disciplines, have produced a
splendid piece of work which presents highly
relevant information on a complex and chal-
lenging subject. This book will greatly assist
physicians in providing optimal care for pa-
tients with melanocytic skin lesions.
Helmut Kerl
Professor & Chairman
Department of Dermatology
Medical University of Graz
Austria
Preface
At the beginning of many scientific endeavors
there is an idea shared by a small group of en-
thusiastic people. This was the case with our
group, friends and colleagues from Austria, Ita-
ly, and the United States. Our idea was to write a
color atlas of melanocytic skin lesions, with
particular emphasis on the morphological di-
mension, using a systematic and logical ap-
proach. As practicing dermatologists with back-
grounds in dermoscopy and dermatopathology,

we wanted to describe the many faces of benign
and malignant pigmented skin lesions based on
clinico-pathological and dermoscopic−patho-
logical correlations. Together with a large group
of distinguished dermatologists from around
the world, we prepared this atlas.
In 1894 Paul Gerson Unna published the text-
book Histopathology of Skin Diseases. His well-
known saying on the relationship between der-
matology and histopathology has been slightly
modified by us and now reads as follows: “The
dermatologist is fortunate in being able to study
the clinical and dermoscopic picture with his/
her histologically trained eye and the micro-
scopic picture with his/her clinically and der-
moscopically trained eye.” In this spirit we hope
that you enjoy reading this atlas and that it will
help you in your daily practice.
H. Peter Soyer
Giuseppe Argenziano
Rainer Hofmann-Wellenhof
Robert Johr
I.1 e Morphologic Dimension
in the Diagnosis of Melanocytic
Skin Lesions . . . . . . . . . . . . . . . . . . . . . . 1
H. Peter Soyer
and Elisabeth M.T. Wurm
I.2 Clinical Examination
of Melanocytic Neoplasms
Including ABCDE Criteria . . . . . . . . . 3

Alfred W. Kopf
I.3 Dermoscopic Examination . . . . . . . . . 7
Ralph P. Braun, Harold S. Rabinovitz,
Margaret Oliviero, Alfred W. Kopf,
Jean-Hillaire Saurat, Luc omas
I.4 Melanoma: the Morphological
Dimension . . . . . . . . . . . . . . . . . . . . . . 23
Lorenzo Cerroni
II.1 Laser-Scanning Confocal
Microscopy . . . . . . . . . . . . . . . . . . . . . . 39
Salvador González and Allan Halpern
II.2 Automatic Diagnosis . . . . . . . . . . . . . 47
Josef Smolle
II.3 Multispectral Image Analysis . . . . . . 52
Dina Gutkowicz-Krusin
and Harold Rabinovitz
II.4 Teledermatology . . . . . . . . . . . . . . . . . 57
Cesare Massone,
Elisabeth M.T. Wurm,
Rainer Hofmann-Wellenhof,
Gian Piero Lozzi, H. Peter Soyer
III.1 e Life of Melanocytic Nevi . . . . . . 61
Harald Kittler
III.2 Acral Nevus . . . . . . . . . . . . . . . . . . . . . 66
Masaru Tanaka, Masayuki Kimoto,
Toshiaki Saida
III.3 Agminated Nevus . . . . . . . . . . . . . . . . 75
Ulrike Weigert and Wilhelm Stolz
III.4 Blue Nevus . . . . . . . . . . . . . . . . . . . . . . 78
Gerardo Ferrara

and Giuseppe Argenziano
III.5 Atypical (Dysplastic) Nevus . . . . . . . 87
Rainer Hofmann-Wellenhof
and
H. Peter Soyer
III.6 Combined Nevus . . . . . . . . . . . . . . . . 97
Horacio Cabo
III.7 Common Nevus . . . . . . . . . . . . . . . . 102
Rainer Hofmann-Wellenhof
and H. Peter Soyer
III.8 Congenital Melanocytic Nevi . . . . . 106
Alon Scope, Cristiane Benvenuto-
Andrade, Ashfaq A. Marghoob
III.9 Melanocytic Nevi on the Genitalia
and Melanocytic Nevi
on Other Special Locations . . . . . . . 119
Ingrid H. Wolf
III.10 Halo Nevus . . . . . . . . . . . . . . . . . . . . 124
Alessandro Di Stefani
and Sergio Chimenti
III.11 Irritated Nevus
and Meyerson’s Nevus . . . . . . . . . . . 129
Regina Fink-Puches,
Iris Zalaudek,
Rainer Hofmann-Wellenhof
III.12 Melanocytic Lesions
in Darker Racial Ethnic Groups . . . 135
Heather Woolery-Lloyd
III.13 Miescher Nevus . . . . . . . . . . . . . . . . . 139
Steven Q. Wang, Harold H.

Rabinovitz, Alfred W. Kopf
Contents
XII Contents
III.14 Nevi with Particular Pigmentation:
Black, Pink, and White Nevus . . . . 142
Iris Zalaudek, Robert Johr,
Bernd Leinweber
III.15 Recurrent Nevus . . . . . . . . . . . . . . . . 147
Andreas Blum
III.16 Spitz Nevus and Its Variants . . . . . . 151
Gerardo Ferrara, Elvira Moscarella,
Caterina M. Giorgio,
Giuseppe Argenziano
III.17 Syndromes Involving
Melanocytic Lesions . . . . . . . . . . . . . 164
Cheryl G. Aber,
Elizabeth Alvarez Connelly,
Lawrence A. Schachner
III.18 Nail Apparatus Nevus (Subungual
Nevus, Nail Matrix Nevus) . . . . . . . 173
Luc omas
III.19 Unna Nevus . . . . . . . . . . . . . . . . . . . . 181
Susana Puig and Josep Malvehy
IV.1 Epidemiology of Melanoma . . . . . . 185
Scott Kitchener
IV.2 Acral Melanoma . . . . . . . . . . . . . . . . 196
Toshiaki Saida, Hiroshi Koga,
Yoriko Yamazaki, Masaru Tanaka
IV.3 Amelanotic Melanoma . . . . . . . . . . . 204
Jürgen Kreusch

IV.4 Early Evolution of Melanoma
(Small-Diameter Melanoma) . . . . . 213
Robert J. Friedman, Melanie Warycha,
Michele Farber, Dina Gutkowicz-
Krusin, Harold Rabinovitz,
David Polsky, Margaret Oliviero,
Darrell S. Rigel, Lori Kels,
Edward R. Heilman, Alfred W. Kopf
IV.5 False-Negative Melanomas . . . . . . . 221
Robert Johr and Giuseppe Argenziano
IV.6 Genital Melanoma . . . . . . . . . . . . . . 229
Ingrid H.
Wolf
IV.7 Melanoma of the Face . . . . . . . . . . . 233
Ulrike Weigert and Wilhelm Stolz
IV.8 Melanoma of the Trunk
and Limbs Including Supercial
and Nodular Melanoma . . . . . . . . . . 237
Josep Malvehy and Susana Puig
IV.9 Cutaneous Metastatic Melanoma . . 260
Maria Antonietta Pizzichetta
IV.10 Scalp Melanoma . . . . . . . . . . . . . . . . 265
Iris Zalaudek, Jason Giacomel,
Bernd Leinweber
IV.11 Nail Apparatus Melanoma
(Subungual Melanoma,
Nail Matrix Melanoma) . . . . . . . . . . 270
Luc omas
V.1 Pigmented Basal Cell Carcinoma . . 279
Scott W. Menzies

V.2 Dermatobroma . . . . . . . . . . . . . . . . 286
Domenico Piccolo and Ketty Peris
V.3 Lentigines Including Lentigo
Simplex, Reticulated Lentigo
and Actinic Lentigo . . . . . . . . . . . . . 290
Paolo Carli and Camilla Salvini
V.4 Squamous Cell Carcinoma
Including Actinic Keratosis, Bowens
Disease, Keratoacanthoma, and Its
Pigmented Variants . . . . . . . . . . . . . 295
Iris Zalaudek, Jason Giacomel,
Bernd Leinweber
V.5 Vascular Lesions . . . . . . . . . . . . . . . . 303
Fezal Özdemir
V.6 Seborrheic Keratosis Including
Lichen Planus-like Keratosis . . . . . . 313
Robert Johr
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . 329
List of Contributors
C. Aber
Division of Pediatric Dermatology
Department of Dermatology
and Cutaneous Surgery
University of Miami
Miller School of Medicine
Cedars Medical Center
1295 NW 14th Street, Suite K
Miami, Florida 33125
E-mail:
E. Alvarez Connelly

Division of Pediatric Dermatology
Department of Dermatology
and Cutaneous Surgery
University of Miami, Miller School of Medicine
Cedars Medical Center
1295 NW 14th Street, Suite K
Miami, Florida 33125
USA
E-mail:
G. Argenziano
Department of Dermatology
Second University of Naples
Nuovo Policlinico − Edificio 13
Via Pansini 5
80131 Naples
E-mail:
C. Benvenuto-Andrade
Research Dermatologist
Photomedicine and Telemedicine Laboratory
Federal University of Rio Grande do Sul
Porte Alegre
Brazil
E-mail:
A. Blum
Associate Professor of Dermatology
Seestraße 3a
78464 Konstanz
Germany
E-mail:
R.P. Braun

Department of Dermatology
University Hospital Zurich
8091 Zurich
Switzerland
E-mail:
H. Cabo
Section of Dermatology
Instituto de Investigaciones Médicas
“A. Lanari”
University of Buenos Aires
Argentina
E-mail:
P. Carli †
Dipartimento di Scienze Dermatologiche
Universita’ di Firenze
Via degli Alfani, 37
50121 Florence
Italy
† Deceased
L. Cerroni
Department of Dermatology
Medical University of Graz
Auenbruggerplatz 8
8036 Graz
Austria
E-mail:
S. Chimenti
Department of Dermatology
University of Rome “Tor Vergata”
PTV − Policlinico di Tor Vergata

Viale Oxford 81
00133 Rome
Italy
E-mail:
A. Di Stefani
Department of Dermatology
University of Rome “Tor Vergata”
PTV − Policlinico di Tor Vergata
Viale Oxford 81
00133 Rome
Italy
E-mail:
M. Farber
Department of Dermatology
New York University School of Medicine
550 First Avenue
New York, NY 10016
USA
E-mail:
G. Ferrara
Pathologic Anatomy Service
Gaetano Rummo General Hospital
Via dell’Angelo 1
82100 Benevento
Italy
E-mail:
R. Fink-Puches
Department of Dermatology
Medical University Graz
Auenbruggerplatz 8

8036 Graz
Austria
E-mail:
R.J. Friedman
Oncology Section
Department of Dermatology
New York University School of Medicine
550 First Avenue
New York, NY 10016
USA
E-mail:
J.S. Giacomel
Private Practice
11 Mends Street
South Perth
Western Australia 6151
Australia
E-mail:
C.M. Giorgio
Department of Dermatology
Second University of Naples
Via S. Pansini 5
80131 Naples
Italy
E-mail:
S. González
Dermatology Service
Memorial Sloan-Kettering Cancer Center
New York, NY 10022
USA

E-mail:
D. Gutkowicz-Krusin
Electro-Optical Sciences, Inc.
1 Bridge Street
Irvington, NY 10533
USA
E-mail:
A. Halpern
Dermatology Service
Memorial Sloan-Kettering Cancer Center
New York, NY 10022
USA
E-mail:
E.R. Heilman
Department of Dermatology
SUNY Health Science Center at Brooklyn
Brooklyn, N.Y.
USA
E-mail:
XIV List of Contributors
R. Hofmann-Wellenhof
Department of Dermatology
Medical University of Graz
Auenbruggerplatz 8
8036 Graz
Austria
E-mail:
R.H. Johr
Pigmented Lesion Clinic
School of Medicine

University of Miami
Miami, FL 33136
USA
E-mail:
M. Kimoto
Department of Dermatology
Keio University School of Medicine
35 Shinanomachi, Shinjyuku-ku
Tokyo 160-8582
Japan
E-mail:
S. Kitchener
Primary Care Skin Cancer Medicine Unit
School of Medicine
University of Queensland
Herston Road
Herston 4006
Australia
E-mail:
H. Kittler
Department of Dermatology
Medical University of Vienna
Waehringer Guertel 18−20
1090 Vienna
Austria
E-mail:
H. Koga
Department of Dermatology
Shinshu University School of Medicine
3-1-1 Asahi

Matsumoto 390-8621
Japan
E-mail:
A.W. Kopf
The Ronald O. Perelman Department
of Dermatology
New York University School of Medicine
550 First Avenue
New York, NY 10016
USA
E-mail:
J. Kreusch
Dermatological Practice
Skin Cancer Diagnostic Center
Moislinger Allee 95
23558 Luebeck
Germany
E-mail: juergen.kreusch @web.de
B. Leinweber
Department of Dermatology
Medical University of Graz, Austria
Auenbruggerplatz 8
8036 Graz
Austria
E-mail:
G.P. Lozzi
Department of Dermatology
University of L’Aquila, Italy
Via Vetoio − Coppito 2
67100 L’Aquila

Italy
E-mail:
J. Malvehy
Melanoma Unit
Department of Dermatology
Hospital Clinic
Villarroel 170
08036 Barcelona
Spain
E-mail:
A.A. Marghoob
Section of Dermatology
Memorial Sloan-Kettering Cancer Center
160 East 53rd Street, 2nd floor
New York, NY 10022
USA
E-mail:
List of Contributors XV
C. Massone
Department of Dermatology
Medical University Graz
Auenbruggerplatz 8
A-8036 Graz
Austria
E-mail:
S.W. Menzies
Sydney Melanoma Diagnostic Centre
2nd Floor, Gloucester House
Royal Prince Alfred Hospital
Missenden Road

Camperdown NSW 2050
Australia
E-mail:
E. Moscarella
Department of Dermatology
Second University of Naples
Via S. Pansini 5
80131 Naples
Italy
E-mail:
M. Oliviero
Department of Dermatology
University of Miami School of Medicine
Miami, FL 33324
USA
E-mail:
F. Özdemir
Department of Dermatology
Medical Faculty
Ege University
35100 Bornova Izmir
Turkey
E-mail:
K. Peris
Department of Dermatology
University of L’Aquila
Via Vetoio − Coppito 2
67100 L’Aquila
Italy
E-Mail:

D. Piccolo
Department of Dermatology
University of L’Aquila
Via Vetoio − Coppito 2
67100 L’Aquila
Italy
E-Mail:
M.A. Pizzichetta
Division of Medical Oncology C
Oncology Prevention
Centro di Riferimento Oncologico
National Cancer Institute
Via Pedemontana Occidentale 12
33081 Aviano –PN
Italy
E-mail:
D. Polsky
Department of Dermatology
New York University School of Medicine
550 First Avenue
New York, NY 10016
USA
E-mail:
H.S. Rabinovitz
Skin and Cancer Associates
201 N.W. 82nd Avenue
Plantation, FL 33324
USA
E-mail:
D.S. Rigel

Department of Dermatology
New York University School of Medicine
Adjunct Clinical Professor
Department of Dermatology
Mount Sinai School of Medicine
New York, NY
USA
E-mail:
S. Puig
Melanoma Unit
Department of Dermatology
Hospital Clínic
Villarroel 170
08036 Barcelona
Spain
E-mail:
XVI List of Contributors
T. Saida
Department of Dermatology
Shinshu University School of Medicine
3-1-1 Asahi
Matsumoto 390-8621
Japan
E-mail:
C. Salvini
Department of Dermatological Sciences
University of Florence
Via della Pergola 58−60
50121 Florence
Italy

E-mail:
J H. Saurat
Pigmented Skin Lesion Unit
Department of Dermatology
University Hospital Geneva
24 rue Micheli Du Crest
1211 Geneva 14
Switzerland
E-mail:
L.A. Schachner
Division of Pediatric Dermatology
University of Miami, Miller School of Medicine
Department of Dermatology and Cutaneous
Surgery
1600 NW 10th Avenue
Rosenstiel Bldg. Room 2023A
Miami FL 33136
USA
E-mail:
L. Schneider-Kels
Department of Dermatology
New York University School of Medicine
550 First Avenue
New York, NY 10016
USA
E-mail:
A. Scope
Section of Dermatology
Memorial Sloan-Kettering Cancer Center
160 East 53rd Street, 2nd floor

New York, NY 10022
USA
E-mail:
J. Smolle
Institute of Medical Informatics,
Statistics and Documentation
Medical University of Graz
Billrothgasse 18a/7
8010 Graz
Austria
E-mail:
H.P. Soyer
School of Medicine
University of Queensland
Australia
W. Stolz
Abteilung für Dermatologie,
Allergologie und Umweltmedizin
Krankenhaus München Schwabing
Kölner Platz 1
80804 Munich
Germany
E-mail:
M. Tanaka
Department of Dermatology
Tokyo Women’s Medical University
Medical Center East
2-1-10 Nishi-Ogu, Arakawa-ku
Tokyo 116-8567
Japan

E-mail:
L. Thomas
Department of Dermatology
Hotel Dieu
69288 Lyon Cedex 02
France
E-mail:
S.Q. Wang
Department of Dermatology
Mayo Mail Code 98
420 Delaware Street S.E.
Minneapolis, MN 55455
USA
E-mail:
List of Contributors XVII
The Queensland Institute of Dermatology
Brisbane, QLD 4102
Princess Alexandra Hospital
E-mail:
M. Warycha
Department of Dermatology
New York University School of Medicine
550 First Avenue
New York, NY 10016
USA
E-mail:
U. Weigert
Abteilung für Dermatologie,
Allergologie und Umweltmedizin
Krankenhaus München Schwabing

Kölner Platz 1
80804 München
Germany
E-mail:
I.H. Wolf
Department of Dermatology
Medical University Graz
Auenbruggerplatz 8
8036 Graz
Austria
E-mail:
H. Woolery-Lloyd
Department of Dermatology
and Cutaneous Surgery
School of Medicine
University of Miami
Miami, FL 33136
USA
E-mail:
E.M.T. Wurm
Department of Dermatology
Medical University of Graz
Auenbruggerplatz 8
8036 Graz
Austria
E-mail:
Y. Yamazaki
Department of Dermatology
Shinshu University School of Medicine
3-1-1 Asahi

Matsumoto 390-8621
Japan
E-mail:
I. Zalaudek
Department of Dermatology
Medical University Graz
Auenbruggerplatz 8
8036 Graz
Austria
E-mail:
XVIII List of Contributors
scopic features, relevant clinical differential di-
agnosis, histopathology, as well as practical as-
pects of management. Core messages recapitulate
the most pertinent facets of each entity.
This introductory chapter, therefore, can be
considered a plea for recognition of the signifi-
cance, and the unchanging importance, of the
human eye and the human neural network for
achieving diagnosis in the protean field of mela-
nocytic skin lesions. We currently are on the
edge of the development of new technologies,
such as imaging technologies and molecular-
biologic tests, for identifying individuals at risk
and for refining the benign/malignant thresh-
old. These new technologies are challenging the
currently well-accepted morphologic methods
including histopathology. However, the present
reality, even in high-tech countries, is that der-
matologists are, and most probably will remain,

at the forefront of diagnosing and treating skin
cancers as well as managing melanocytic skin
lesions.
I.1.2 The Benign/Malignant Threshold
in Morphology
The boundary between benignity and malig-
nancy is not as sharp as our established catego-
ries would like them to be. Dermoscopic – but
also histopathologic – diagnoses, not to men-
tion clinical diagnosis, are subjective as well as
objective. In 1962 these facts were well depicted
for the histopathologic diagnosis by Rambo who
stated that “pathologists are physicians and hu-
man beings. They […] traditionally have been
regarded to be more scientific than many of
their colleagues. A mystic perversion of this as-
sumption prevails among those clinicians who
Chapter I.1
The Morphologic Dimension in the
Diagnosis of Melanocytic Skin Lesions
H. Peter Soyer and Elisabeth M.T. Wurm
I.1
Contents
I.1.1 A Color Atlas of Melanocytic Lesions
of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
I.1.2 e Benign/Malignant reshold
in Morphology . . . . . . . . . . . . . . . . . . . . . . . . . . 1
I.1.3 A New Era of “Clinicoimaging”
Diagnosis in Dermatology . . . . . . . . . . . . . . . .2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

I.1.1 A Color Atlas of Melanocytic
Lesions of the Skin
The book in your hands has been designed basi-
cally as an atlas entitled Color Atlas of Melano-
cytic Lesions of the Skin and focuses on the mor-
phologic dimension of melanocytic skin lesions.
It encompasses all the classical methods of mor-
phology such as the clinical and dermoscopic
examination and dermatopathology, as well as
the most up-to-date diagnostic approaches such
as laser scanning in-vivo microscopy, multi-
spectral image analysis, automatic diagnosis,
and teledermatology. With the exception of the
chapters on automatic diagnosis and on multi-
spectral analysis, all chapters focus on the mor-
phologic dimension, albeit in its various facets,
thus justifying the title of this book.
The core of this book represents an atlas with
clinical, dermoscopic, and histopathologic im-
ages of the many faces of melanocytic nevi, the
various types of melanomas, as well as the vari-
able features of non-melanocytic pigmented
skin tumors. Each of these well-illustrated enti-
ties are presented following the same ductus
characterized by definition, clinical and dermo-
2 H. P. Soyer, E. M.T. Wurm
I.1
believe that the pathologist, given only a piece of
the patient’s tissue, has all the other ingredients
necessary to produce a statement of absolute

truth at the end of his report. More dangerous to
the mankind is a pathologist with the same con-
cept…” [1]. Even today it is not easy at all to find
references which indicate that expert patholo-
gists sometimes have great difficulties in recog-
nizing, for example, the threshold separating
carcinoma in situ or melanoma in situ from
atypia or dysplasia. Interestingly, many dermos-
copists reveal more insight with regard to their
diagnostic limitations. In a recent issue of the
“Archives of Dermatology” an article by Skvara
et al. entitled “Limitations of dermoscopy in the
recognition of melanoma” focuses on the limi-
tations of dermoscopy in the diagnosis of very
early, and mainly featureless, melanomas [2].
The authors report that baseline dermoscopic
patterns of 262 melanocytic nevi and 63 mela-
nomas, which were followed by digital dermos-
copy and finally excised because of changes over
time, did not differ substantially from each oth-
er. Suffice it to say that histopathology repre-
sented the gold standard in this study.
I.1.3 A New Era of “Clinicoimaging”
Diagnosis in Dermatology
In 2005 June Robinson, the editor of the “Ar-
chives of Dermatology,” wrote in an editorial
titled “Biotechnology succeeds in revolutioniz-
ing medical sciences” the following statement:
“Given the unique visual learning patterns of
our discipline, it is not surprising that we eager-

ly adapt emerging bioimaging techniques. [ ]
We are beginning to move away from clinico-
pathologic diagnosis into an era of ‘clinicoimag-
ing’ diagnosis” [3]. The introduction of these
new ‘clinicoimaging’ techniques in the near fu-
ture certainly will have a major impact on the
current dermatologic practice, although there
will be a need to define new quality standards in
order to integrate these techniques into the dai-
ly workflow. We should not forget, however, that
all of these new “clinicoimaging” techniques
have, like every other purely morphologic meth-
od, limitations due to methodologic drawbacks,
and sometimes even due to personal restraints.
In addition, we are presently also on the edge of
a period of radical change in histopathology, as
DNA and RNA can be analyzed by advanced
technologies even from archival paraffin-em-
bedded material, allowing us to make diagnos-
tic leaps and bounds [4]. This “new biology” will
certainly also affect the benign/malignant
threshold in pathology, and a more functional
approach to establish the risk associated with
sharply defined categories will substitute the
fanciful separation of benign from malignant
[4, 5]; thus, one can easily foresee that in the fu-
ture the conventional morphologic methods
will probably be substituted by these new “clini-
coimaging” techniques and by novel microbio-
logic methods. Until then, a combined approach

linking the most legitimate and effective mor-
phologic methods, namely, clinical examina-
tion, dermoscopy, and histopathology, will
strengthen the validity of classical morphology
[6, 7]. In this spirit this introductory chapter,
and this atlas, has been written.
References
1. Rambo ON. e limitations of histologic diagnosis.
Progr Radiat er 1962; 2: 215–224
2. Skvara H, Teban L, Fiebiger M, Binder M, Kittler
H. Limitations of dermoscopy in the recognition of
melanoma. Arch Dermatol 2005; 141: 155–160
3. Robinson JK, Callen JP. Biotechnology succeeds rev
-
olutionizing medical sciences. Arch Dermatol 2005;
141: 133–134
4. Quirke P, Mapstone N. e new biology: histopathol-
ogy. Lancet 1999; 354: SI26–SI31
5. Foucar E. Carcinoma-in-situ of the breast: Have pa
-
thologists run amok? Lancet 1996; 347: 707–708
6. Soyer HP, Massone C, Ferrara G, Argenziano G.
Limitations of histopathologic analysis in the recog
-
nition of melanoma: a plea for a combined diagnostic
approach of histopathologic and dermoscopic evalu-
ation. Arch Dermatol 2005; 141: 209–211
7. Bauer J, Leinweber B, Metzler G, Blum A, Hofmann-
Wellenhof R, Leitz N, Dietz K, Soyer HP, Garbe C.
Correlation with digital dermoscopic images can

help dermatopathologists to diagnose equivocal skin
tumours. Br J Dermatol 2006;155: 546–551
Ideally, the patient should lie in a horizontal
position on the examining table. The entire an-
terior and posterior cutaneous surface of the
patient is examined with the patient assuming a
supine, then a prone, position. Intertriginous
areas, including the axillae, groin, and interdig-
ital webs of the hands and feet, plus the nail ap-
paratus, are included in the complete cutaneous
examination.
Finally, examination of the scalp is best ac-
complished by the use of a hair blower that parts
the hair down to the skin of the scalp for view-
ing.
I.2.2 ABCDE Criteria and
Other Diagnostic Methods
The acronym ABCDE was created as a simple
mnemonic to alert both the general community
and health care workers of some of the key fea-
tures of melanoma. The acronym stands for:
A = Asymmetry. No matter where the lesion
is bisected, the one half will not match the other
in silhouette and/or lesion content.
B = Border irregularity. The perimeter of the
lesion is uneven, undulating, ragged, notched,
or blurred.
C = Color. Multiple shades of tan, brown,
black, red, white, and blue are admixed, produc-
ing a mottled appearance.

D = Diameter >6 mm. The largest diameters
of most melanomas will exceed 6 mm at a point
in their evolution that can be identified. This is
not an inviolate rule, and currently a significant
portion of melanomas are diagnosed by experts
when these cancers are 6 mm or less in diame-
ter.
Chapter I.2
Clinical Examination of Melanocytic
Neoplasms Including ABCDE Criteria
Alfred W. Kopf
I.2
Contents
I.2.1 Clinical Recognition of Melanoma . . . . . . . . . 3
I.2.2 ABCDE Criteria and Other
Diagnostic Methods . . . . . . . . . . . . . . . . . . . . . 3
I.2.1 Clinical Recognition of Melanoma
The clinical recognition of melanoma in its ear-
ly phases of progression is exceedingly impor-
tant since the total surgical removal of such
lesions is almost invariably curative. When the
clinical recognition is delayed, the opportunity
for distant metastases increases and the progno-
sis is guarded since treatment of such metasta-
ses is problematic.
Since dysplastic nevi and melanomas can
occur on any area of the cutaneous surface, it is
mandatory that a complete cutaneous examina-
tion be performed on every patient regardless of
age. All new patients should have a complete cu-

taneous examination either at the initial visit or
in the near future. The frequency for an estab-
lished patient depends on their history. Those
patients with a history of actinic keratosis, dys-
plastic nevi, non-melanoma skin cancer or mel-
anoma should be seen every 6 months for a
complete cutaneous examination.
The examining room should have proper
illumination and the temperature should be
comfortable for the patient, who should be
completely undressed except – maybe – for the
examination gown, which should be provided.
The examiner should have available a simple
magnifying lens, an instrument for dermosco-
py, and an ultraviolet lamp (“Woods light”) for
special examinations such as looking for areas
of hyper- or hypopigmentation on the skin.
4 A.W. Kopf
I.2
E = Evolving. While common melanocytic
nevi evolve slowly and reach a final stage of
growth usually within the first few decades of
life, melanomas usually undergo constant
change in size, shape, shades of color, symme-
try, symptoms (especially pruritus, scaliness,
oozing, bleeding), or surface alterations [ero-
sion, ulceration, papule, and/or nodule forma-
tion and the development of areas of hypopig-
mentation and depigmentation (a clinical
correlate of spontaneous regression)].

Another easy mnemonic are the three Cs of
melanoma standing for: color, contour, and
change.
The diagnostic method of the Glasgow 7-
point checklist for diagnosis of melanoma in-
cludes: (a) change in size; (b) irregular shape; (c)
irregular color (major criterion); (d) diameter at
least 7 mm; (e) inflammation; (f) oozing/bleed-
ing; and (g) change in sensation (minor criteri-
on).
The features described above are suggestive
of melanoma (especially superficial spreading
melanoma), but they also appear in benign le-
sions (such as atypical nevi), thus causing diag-
nostic difficulties. Nodular melanomas, on the
other hand, often appear as small and symmet-
ric round nodules, smaller than 6 mm in diam-
eter, the only hint of malignancy being a clinical
history of evolution and change. These limita-
tions to specificity and sensitivity of naked-eye
examination can be reduced by dermoscopy as a
useful aid in the in-vivo differentiation of such
lesions (see Chap. I.3).
Furthermore, total cutaneous photography
can be performed for patients who have many
melanocytic nevi (especially when atypical).
Baseline total-cutaneous photographs (Fig. I.2.1)
are very helpful in identifying significant chang-
es in pre-existing lesions and identifying new
melanocytic neoplasms on subsequent follow-

up clinical examinations.
Last but not least, patients should be instruct-
ed and encouraged to regularly perform self-ex-
amination of their skin (Fig. I.2.2).
Fig. I.2.1. Illustrations for dierent views taken of to-
tal-body photographs. Sites photographed are bound by
dashed lines or solid-line rectangles. Top: On anterior and
posterior surfaces of body, all demarcated areas (shaded
and unshaded) are photographed. On lateral aspects of
body, only shaded areas are photographed
Clinical Examination of Melanocytic Neoplasms Chapter I.2 5
Fig. I.2.2. Self-examination of the skin (continuation see next page)
C Core Messages
■ It is mandatory that a complete
cutaneous examination be performed
on every patient regardless of her/his
age.
■ The examination should include
examination of intertriginous areas
including axillae, groin, and interdigi-
tal webs of hands and feet, as well as
nail apparatus and scalp.
■ Features of melanoma can be memo-
rized by the acronym ABCDE: Asym-
metry; Borders; Color; Diameter;
and Evolution.
■ The diagnostic method of the Glasgow
7-point checklist for diagnosis of
melanoma includes: (a) change in size;
(b) irregular shape; (c) irregular color

(major criterion); (d) diameter at least
7 mm; (e) inflammation; (f) oozing/
bleeding; and (g) change in sensation
(minor criterion).
■ Patients should be encouraged to
regularly perform a self-examination
of their skin.
6 A.W. Kopf
I.2
Fig. I.2.2. (continued)
I.3.1 Introduction
Dermoscopy (also known as epiluminescence
microscopy, dermatoscopy, amplified surface
microscopy) is an in-vivo method that has been
reported to be a useful tool for the early recogni-
tion of melanoma and the differential diagnosis
of pigmented lesions of the skin [1, 2]. Its use in-
creases diagnostic accuracy between 5 and 30%
over clinical visual inspection, depending on
the type of skin lesion and the experience of the
physician. This was confirmed by two recent
evidence-based publications from a meta-analy-
sis of the literature [3].
I.3.2 Physical Aspects
Light is either reflected, dispersed, or absorbed
by the stratum corneum due to its refraction in-
dex and its optical density, which is different
from air; thus, deeper underlying structures
cannot be adequately visualized. The use of
immersion liquids renders the skin surface

translucent and reduces reflections, so that un-
derlying structures will become visible. The ap-
plication of a glass plate flattens the skin surface
and provides an even surface. Optical magnifi-
cation is used for examination. Taken together,
these optical means allow the visualization of
certain epidermal, dermo-epidermal, and der-
mal structures. As immersion liquid we recom-
mend the use of 60° alcohol (ethanol) which can
Chapter I.3
Dermoscopic Examination
Ralph P. Braun, Harold S. Rabinovitz, Margaret Oliviero,
Alfred W. Kopf, Jean-Hillaire Saurat, Luc omas
I.3
Contents
I.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
I.3.2 Physical Aspects . . . . . . . . . . . . . . . . . . . . . . . . 7
I.3.3 Equipment for Dermoscopy . . . . . . . . . . . . . . 8
I.3.4 Dermoscopic Criteria . . . . . . . . . . . . . . . . . . . 9
I.3.4.1 Colors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
I.3.4.2 Blood Vessels. . . . . . . . . . . . . . . . . . . . . . . . . . . 9
I.3.5 Dermoscopic Structures . . . . . . . . . . . . . . . . .11
I.3.5.1 Pigment Network . . . . . . . . . . . . . . . . . . . . . . . 11
I.3.5.2 Dots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
I.3.5.3 Globules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
I.3.5.4 Branched Streaks . . . . . . . . . . . . . . . . . . . . . . .12
I.3.5.5 Streaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
I.3.5.6 Structureless Areas . . . . . . . . . . . . . . . . . . . . .13
I.3.5.7 Blotches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
I.3.5.8 Regression . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

I.3.5.9 Blue-White Veil . . . . . . . . . . . . . . . . . . . . . . . . 13
I.3.5.10 Milia-like Cysts . . . . . . . . . . . . . . . . . . . . . . . .13
I.3.5.11 Comedo-like Openings
(Crypts, Pseudofollicular Openings) . . . . . . 13
I.3.5.12 Fingerprint-like Structures . . . . . . . . . . . . . .14
I.3.5.13 Moth-Eaten Border . . . . . . . . . . . . . . . . . . . . . 14
I.3.5.14 Fissures and Ridges
(“Brain-like” Appearance) . . . . . . . . . . . . . . . 14
I.3.5.15 Leaf-like Areas . . . . . . . . . . . . . . . . . . . . . . . . . 14
I.3.5.16 Spoke-Wheel-like Structures . . . . . . . . . . . . . 14
I.3.5.17 Large Blue-Gray Ovoid Nests . . . . . . . . . . . . 14
I.3.5.18 Multiple Blue-Gray Globules . . . . . . . . . . . . . 14
I.3.6 Dierential Diagnosis
of Pigmented Lesions of the Skin . . . . . . . . .15
I.3.7 ABCD Rule of Dermatoscopy [11, 12] . . . . . 19
I.3.7.1 Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
I.3.7.2 Border. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
I.3.7.3 Colors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
I.3.7.3 Dermoscopic Structures . . . . . . . . . . . . . . . . .19
I.3.7.3.1 Seven-Point Checklist . . . . . . . . . . . . . . . . . . .20
I.3.7.3.2 Menzies Method . . . . . . . . . . . . . . . . . . . . . . . .20
I.3.7.3.3 ree-Point Checklist . . . . . . . . . . . . . . . . . . .21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
8 R. P. Braun, H. S. Rabinovitz, M. Oliviero et al.
I.3
be applied directly on the skin using an eye
dropper bottle [4]. The advantages are that eth-
anol results in the best image quality and the
least air inclusions. It evaporates immediately,
does not have to be wiped off, and does not stain

the patient’s clothing or underwear. In areas
close to the eyes or to the mucosa, as well as for
the examination of the nail apparatus, we rec-
ommend instead the use of a gel (ultrasound gel,
cosmetic gel, etc.). A cosmetic gel does not burn
the eyes and, most importantly, it fills out very
nicely the gap between the convex nail surface
and the handheld device. As an alternative to the
immersion technique, some devices use polar-
ized light in order to reduce the surface reflec-
tions. This technique allows a faster examina-
tion of the patient, but if the patient has dry skin
the use of immersion liquid is still required.
I.3.3 Equipment for Dermoscopy
As mentioned, dermoscopy requires optical
magnification and liquid immersion. Specially
designed handheld devices with 10–20 times
magnification are commercially available (Der-
matoscope Delta 20, Heine, Herrsching, Ger-
many; DermoGenius Basic, Biocam, Regens-
burg, Germany; Dermlite (3Gen, San Juan
Capistrano, Calif.); see Fig. I.3.1). All devices
mentioned above are devices of the second gen-
eration which have improved optics and illumi-
nation (LED) compared with the older devices
[1]. The optic is designed in such a way that a le-
sion can be examined at distance from the skin.
This is an advantage, because the examination is
much faster and it is more comfortable for both,
the physician and the patient, if the lesion is, for

example, on the face or the genital area.
Photographic documentation can be per-
formed in different ways [1]: The digital camera
is directly attached to a handheld dermatoscope
(coupling adapters are available for most hand-
held devices). In this case, the camera uses the
optics and the illumination of the handheld der-
matoscope. Since the optics of the handheld de-
vices are not designed to fit a camera, the der-
moscopic image is always a bit blurred towards
the periphery, but this is the most inexpensive
way of taking dermoscopy images.
Dermoscopy attachments (lenses) are direct-
ly attached to digital cameras. Their optics and
illumination are designed to fit digital cameras
and they provide the best image quality. These
lenses can only be used with digital cameras
and not for the examination of patients. There
are many different attachments available, but
we mainly use the Dermlite Foto attachment
(3GEN; Fig. I.3.1) or a Dermaphot lens (Heine,
AG) which can be attached to digital SLR cam-
eras. The attachments can be used with differ-
ent cameras and the resolution depends on the
digital camera used. This solution enables con-
veniently taking images of excellent quality.
Fig. I.3.1. A choiceof hand-
held dermatoscopes of the
latest generation (from le to
right): DermoGenius Basic

(Biocam); Delta 20 (Heine);
Dermlite II pro HR (3GEN);
and Dermlite Foto (3GEN)
on a Coolpix 4500 (Nikon)
Dermoscopic Examination Chapter I.3 9
Storage and retrieval remain tricky for both
ways of photo documentation mentioned above,
and by the end of the day one finds himself with
a camera full of images which have to be attrib-
uted to patients and stored in a way that they
can be easily retrieved.
Systems for digital dermoscopy consist of a
video camera which is linked directly to a com-
puter. The lesion can be examined “live” on the
computer screen. These systems offer physicians
many more features than the previous solutions,
such as the possibility of easy storage and re-
trieval of lesions, which is important for follow-
up examinations of suspect lesions. This is a big
advantage, because when the patient leaves the
office, all images (lesions) are correctly stored
and there is no additional work to be done. Some
systems offer even the possibility of computer-
assisted diagnosis and/or teledermoscopy. Since
these systems use a video camera, the resolution
is not as good as with a digital consumer camera
and a dermoscopy attachment, but the image
quality is very good on the computer screen.
Systems for digital dermoscopy offer many more
features and can make life much easier, but their

disadvantages are their high cost and their lack
of portability.
I.3.4 Dermoscopic Criteria
The use of dermoscopy allows the identification
of many different structures, colors, and blood
vessels not seen by naked-eye examination.
I.3.4.1 Colors
Colors play an important role in dermoscopy.
Common colors are light brown, dark brown,
black, blue, blue-gray, red, yellow, and white.
The most important chromophore of the skin,
especially in melanocytic neoplasms, is mela-
nin. The color of melanin as seen with dermos-
copy depends on its localization in the skin. For
example, melanin appears black in the stratum
corneum and the upper epidermis, light to dark
brown in the epidermis, gray to blue-gray in the
papillary dermis, and steel blue in the reticular
dermis. Melanin appears to be blue when it is
localized within the deeper parts of the skin, be-
cause the portions of the visible light with lon-
ger wavelengths (red end of visible spectrum)
are more dispersed than the portions with
shorter wavelengths (blue-violet end of the spec-
trum). The color red is associated with either an
increased number or dilatation of blood vessels,
trauma, or neo-vascularization (see vascular
pattern). The color white is often due to regres-
sion and/or scaring (see Regression).
I.3.4.2 Blood Vessels

In recent publications, blood vessels have gained
much more importance and their morphologi-
cal aspect enables the clinician in many cases to
make the diagnosis, especially in non-pigment-
ed lesions and lesions of non-melanocytic ori-
gin.
The following types of blood vessels have
been described: red lagoons; hairpin vessels;
dotted vessels; “comma”-like vessels; glomeru-
lar vessels; string of pearls; crown vessels; cork-
screw vessels; and arborizing vessels (Table I.3.1)
[5]. An atypical vascular pattern, also called ir-
regular (polymorphous) vessels, may include
linear, dotted, or globular red vessels, irregu-
larly distributed within the lesion. Some of the
vascular patterns may be due to neo-vascular-
ization. For the evaluation of blood vessels, there
has to be as little pressure as possible on the le-
sion during the examination, because otherwise
the vessels are simply compressed and will not
be visible. The use of ultrasound gel for immer-
sion helps to reduce the pressure. An excellent
alternative is the use of non-contact polarized
light examination as used in some handheld
dermatoscopes.
10 R. P. Braun, H. S. Rabinovitz, M. Oliviero et al.
I.3
Table I.3.1. Vascular architecture of pigmented skin lesions. (From [5])
Morphological aspect Correlation
Red lagoons Sharply demarcated globular

structures, red, violaceous,
brownish, bluish, or black
Hemangiomas
or angiokeratomas
Hairpin vessels
Elongated vessels resembling
hairpins
Fine and surrounded by whitish
halo, seborrheic keratosis,
or keratinizing tumor
Irregular and thick melanoma
or Spitz nevus
Dotted vessels
Small vessels resembling
the head of a pin
Vertical vessels seen in Spitz
nevus or melanoma
Observed also in psoriasis and
squamous cell carcinoma
Comma-like
vessels
Resembling the shape
of a comma
Compound or dermal nevus
Clusters of glomerular
vessels
Small- and fine-coiled vessels Bowen’s disease
Observed in melanoma
and stasis dermatitis
String of pearls

Globular vessels following
a serpiginous distribution
Clear cell acanthoma
Crown vessels
Radial wreath-like or individual
vessels at the periphery of the
tumor; white-yellow globules
in the center of the tumor
Sebaceous gland hyperplasia
Corkscrew vessels
Irregular and thick-coiled
vessels
Melanoma including melanoma
metastasis
Arborizing vessels
Resembling the branches
of a tree
Basal cell carcinoma
Irregular poly-
morphous vessels
Multiple vessels with different
shapes including comma,
dotted irregular lines, cork-
screw, glomerular, and others
Melanoma