The role of pattern analysis and the ABCD rule of dermoscopy in the detection of histological atypia in melanocytic naevi

BACKGROUND: Clinical features of melanocytic naevi correlate poorly with the presence, histopathologically, of architectural disorder and cytological atypia, making the detection of histological atypia by means of macroscopic appearance unreliable. OBJECTIVES: The aim of this study was to investigate the diagnostic effectiveness of dermoscopy in the non-invasive detection of histological atypia in naevi. METHODS: Observers blinded for histological diagnosis classified a series of 168 melanocytic naevi as common or atypical on the basis of their clinical features and on their dermoscopic profile. The diagnostic performance of both methods compared with the true (histopathological) diagnosis was assessed. RESULTS: Dermoscopy using pattern analysis showed better results than clinical examination in the non-invasive detection of naevi with architectural disorder with or without cytological atypia (diagnostic accuracy 45% vs. 28%). A statistically significant difference in the frequency of dermoscopic parameters between atypical and common naevi was found for atypical pigment network (39% vs. 17%, P = 0.001) and dermoscopic regression structures (13% vs. 2%, P = 0.008). Dermoscopic features, which best predicted histological atypia in naevi, were regression structures (white scar-like areas or peppering), irregular vascular pattern and grey-blue areas (positive predictive values 83%, 83% and 73%, respectively). In contrast, no statistically significant difference in the mean values of the ABCD score between common and atypical naevi was found. The best diagnostic performance of dermoscopy by means of the ABCD rule (cut-off point of 4.0 of total dermoscopy score) was not dissimilar to that of clinical diagnosis (diagnostic accuracy 30%). CONCLUSIONS: Dermoscopy by means of pattern analysis enhances the diagnostic accuracy of dermatologists in the prediction of histological atypia in melanocytic naevi as compared with clinical examination alone.     

Age-related prevalence of dermoscopy patterns in acquired melanocytic naevi

BACKGROUND: Based on the dermoscopic classification of acquired melanocytic naevi, six different dermoscopic types can be distinguished by morphology (globular, globular-reticular, globular-homogeneous, reticular, reticular-homogeneous, homogeneous) and by pigment distribution (uniform, central hyperpigmentation, central hypopigmentation, peripheral hyperpigmentation, peripheral hypopigmentation, multifocal hyper/hypopigmentation). It has been suggested that most individuals harbour one predominant dermoscopic type among their naevi. OBJECTIVES: To evaluate whether the age of the patient influences the predominant naevus pattern observed in individuals with multiple acquired melanocytic naevi. METHODS: Individuals were recruited from the pigmented skin lesion clinic in Graz between July 2000 and February 2001. Individuals with at least 10 melanocytic naevi were selected consecutively until a total of 10 individuals in each of five age groups was obtained. Age groups were: 0-15 years, 16-30 years, 31-45 years, 46-60 years and > 60 years. Digitized images of acquired melanocytic naevi, defined as benign melanocytic proliferations having a diameter of at least 5 mm with a macular component and which were not apparent within the first year of life, were evaluated by dermoscopic criteria. The associations of dermoscopic features as a function of patient age were analysed. We calculated absolute numbers and frequencies, given as percentages, as well as predominance of the dermoscopic types of naevi in the different age groups. RESULTS: Analysis of 1268 naevi revealed that the globular pattern predominated in the youngest age group. By contrast, the reticular and/or homogeneous patterns were increasingly exhibited in naevi from older individuals (older than 15 years). Uniform pigmentation was most common in melanocytic naevi in the youngest age group, while central hyperpigmentation was predominantly seen in the group of individuals aged 16-30 years. CONCLUSIONS: The predominance of dermoscopic types of melanocytic naevi varies according to the individual's age. Awareness of the age-related dermoscopic predominance of melanocytic naevi might allow more accurate recognition of dermoscopic patterns of melanocytic skin lesions that are unusual with respect to the individual's age. This observation may help in the early recognition of some 'banal'-appearing melanomas. Furthermore, the observations made in this study raise interesting questions regarding naevus evolution.     

Pre-operative diagnosis of pigmented skin lesions: in vivo dermoscopy performs better than dermoscopy on photographic images

BACKGROUND: Epiluminescence microscopy (ELM) (dermoscopy, dermatoscopy) is a technique for non-invasive diagnosis of pigmented skin lesions that improves the diagnostic performance of dermatologists. Little is known about the possible influence of associated clinical features on the reliability of dermoscopic diagnosis during in vivo examination. OBJECTIVE: To compare diagnostic performance of in vivo dermoscopy (combined clinical and dermoscopic examination) with that of dermoscopy performed on photographic slides (pure dermoscopy). DESIGN: This case series comprised 256 pigmented skin lesions consecutively identified as suspicious or equivocal during examination in a general dermatological clinic. Clinical examination and in vivo dermoscopy were performed before excision by two trained dermatologists. The same observers carried out dermoscopy on photographic slides at a later time, and these three diagnostic classifications were reviewed together with the histological findings for the individual lesions. This was carried out in a university hospital. RESULTS: In vivo dermoscopy performed better than dermoscopy on photographic slides for classification of pigmented skin lesions compared with histological diagnosis, and both performed better than general clinical diagnosis. In vivo dermoscopic diagnosis of melanoma showed 98.1% sensitivity, 95.5% specificity and 96.1% diagnostic accuracy while dermoscopic diagnosis of melanoma on photographic slides was less reliable with 81.5% sensitivity, 86.7% specificity and 85.2% diagnostic accuracy. In particular, diagnosis of melanoma based on photographic slides led to nine false negative cases (three in situ, six invasive; thickness ranges 0.2-1.5 mm). CONCLUSIONS: In vivo dermoscopy, i.e. combined clinical and dermoscopic examination, is more reliable than dermoscopy on photographic slides. In clinical practice, therefore, in vivo dermoscopy cannot be considered independent from associated clinical characteristics of the lesions, which help the trained observer to reach a more precise classification. This may have implications on the reliability of ELM diagnosis made by an observer not fully trained in the clinical diagnosis of pigmented skin lesions or by a remote observer during digital ELM teleconsultation.     

Proposal of a new classification system for melanocytic naevi

The lack of consensus among clinicians and pathologists due to the mixture of clinical and histopathological features used to define the various melanocytic naevi underscores the need of a better classification system for these benign lesions. We describe a dermoscopic classification system for melanocytic naevi that is directed to clinicians dealing with the early diagnosis of melanoma, as well to pathologists, in order to promote better communication between these different specialists.     

Computer description of colours in dermoscopic melanocytic lesion images reproducing clinical assessment

BACKGROUND: The assessment of colours is essential for the diagnosis of malignant melanoma (MM), both for pattern analysis on dermoscopic images, and when employing semiquantitative methods. OBJECTIVES: To develop a computer program for colour assessment in MM images mimicking the human perception of lesion colours, and to compare the automatic colour evaluation with one performed by human observers. METHODS: A colour palette comprising six colour groups (black, dark brown, light brown, blue-grey, red and white) was created by selecting single colour components inside melanocytic lesion images acquired by means of a digital videomicroscope, and was implemented in the image analysis program. Subsequently, colours were assessed by the computer program on 331 melanocytic lesion images composing our image database, and the results were compared with the evaluation of lesion colours performed by the clinician. RESULTS: The black, white and blue-grey colours were more frequently found in MMs than in naevi, both by the clinicians and by the computer. In MM images we observed 4.27 +/- 1.14 colours (mean + or - SD) per lesion, as opposed to 3.22 +/- 0.68 in naevi. The correlation between clinical and computer evaluation of the colours was very good, with a value of 0.781 for overall assessment. CONCLUSIONS: This innovative method for automatic colour evaluation, reproducing clinical assessment of melanocytic lesion colours, may provide numerical parameters to be employed for computer-aided diagnosis of MM.     

Impact of dermoscopy and short‐term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: a sequential intervention trial

Background Studies have shown the benign to malignant ratio of excised pigmented skin lesions is suboptimal in primary care. Objectives To assess the impact of dermoscopy and short‐term sequential digital dermoscopy imaging (SDDI) on the management of suspicious pigmented skin lesions by primary care physicians. Methods A total of 63 primary care physicians were trained in the use of dermoscopy and SDDI (interventions) and then recruited pigmented lesions requiring biopsy or referral in routine care by naked eye examination. They were then given a dermatoscope and the option of a SDDI instrument, and change of diagnosis and management was assessed. Results Following the use of the interventions on 374 lesions a total of 163 lesions (43·6%) were excised or referred, representing a reduction of 56·4%. Of the 323 lesions confirmed to be benign, 118 (36·5%) were excised or referred, leading to a reduction of 63·5% (P < 0·0005) in those requiring excision or referral. The baseline naked eye examination benign to melanoma ratio was 9·5 : 1 which decreased to 3·5 : 1 after the diagnostic interventions (P < 0·0005). Of the 42 malignant lesions included in the study (34 melanoma, six pigmented basal cell carcinoma and two Bowen disease) only one in situ melanoma was incorrectly managed (patient to return if changes occur) resulting in the correct management of 97·6% and 97·1% of malignant pigmented lesions and melanoma, respectively. Conclusions In a primary care setting the combination of dermoscopy and short‐term SDDI reduces the excision or referral of benign pigmented lesions by more than half while nearly doubling the sensitivity for the diagnosis of melanoma.     

Surveillance of patients at high risk for cutaneous malignant melanoma using digital dermoscopy

BACKGROUND: Dermoscopy has improved the sensitivity and specificity of clinical diagnosis of melanoma from 60% to over 90%. However, in order not to miss melanoma a certain percentage of suspicious but benign lesions has to be excised. OBJECTIVES: To evaluate the dermoscopic changes and the rates of excision in benign melanocytic naevi and cutaneous malignant melanoma in long-term follow-up of high-risk patients using digital dermoscopy. METHODS: Digital dermoscopic images of 2015 atypical melanocytic naevi in 196 high-risk patients were analysed retrospectively. Among others, the following data were collected for each naevus: changes in surface area, overall architecture, dermoscopic patterns and distribution of pigmentation. All tumours suspicious for melanoma or showing asymmetrical changes were excised. RESULTS: During a median follow-up time of 25 months 128 (6.4%) of all naevi showed changes in size or architecture. Eighty-six per cent of all changes in patients who attended more than one visit were observed at the first follow-up visit. Thirty-three lesions showing changes were excised and two melanomas in situ and 31 melanocytic naevi were diagnosed. CONCLUSIONS: Follow-up examinations using digital dermoscopy revealed unchanged morphology in the large majority of melanocytic naevi. Excisions were only performed in cases of asymmetrical growth, asymmetrical changes of pigmentation, or development of dermoscopic features indicative of melanoma. The ratio of 33 lesions excised in order to identify two melanomas in situ seems reasonable and may be further reduced in future.     

Dermoscopic monitoring of melanocytic skin lesions: clinical outcome and patient compliance vary according to follow-up protocols

Background  Dermoscopic monitoring of melanocytic lesions increases the likelihood that featureless melanomas are not overlooked and minimizes the excision of benign lesions.
Objective  To examine clinical outcome and patient compliance using different follow-up protocols.
Methods  A retrospective analysis of 600 lesions from 405 patients (aged 6–79 years) was performed to examine patient compliance and clinical outcome in patients with multiple atypical melanocytic lesions undergoing sequential dermoscopy imaging during short-, medium- or long-term follow-up. Based on the degree of dermoscopic atypical features, patients were scheduled for short-term monitoring with follow-up after 3 months, medium-term monitoring with follow-up after 6 months or long-term monitoring with annual follow-up. Criteria leading to excision of monitored lesions differed according to the follow-up protocol.
Results  In a median follow-up period of 23 months, 54 (9%) lesions were excised, revealing 12 early melanomas (occurring in 3% of monitored patients), one basal cell carcinoma and 41 melanocytic naevi. The melanoma/benign ratio of excised lesions was 1 : 3·4. Seven of 12 melanomas showed changes after two to four visits, corresponding to 8–54 months of follow-up. Patient compliance was 84% for short-term monitoring, 63% for medium-term monitoring and 30% for long-term monitoring.
Conclusions  In patients with multiple naevi sequential dermoscopy imaging is a useful strategy to avoid missing melanomas while minimizing unnecessary excision of benign lesions. For better compliance, the first re-examination should be scheduled at 3 months after the baseline visit. Regular annual follow-up monitoring is also needed to detect slow-growing melanomas in which subtle changes may become apparent only over time.     

Systematic review of dermoscopy and digital dermoscopy/ artificial intelligence for the diagnosis of melanoma

Background Dermoscopy improves diagnostic accuracy of the unaided eye for melanoma, and digital dermoscopy with artificial intelligence or computer diagnosis has also been shown useful for the diagnosis of melanoma. At present there is no clear evidence regarding the diagnostic accuracy of dermoscopy compared with artificial intelligence. Objectives To evaluate the diagnostic accuracy of dermoscopy and digital dermoscopy/artificial intelligence for melanoma diagnosis and to compare the diagnostic accuracy of the different dermoscopic algorithms with each other and with digital dermoscopy/artificial intelligence for the detection of melanoma. Methods A literature search on dermoscopy and digital dermoscopy/artificial intelligence for melanoma diagnosis was performed using several databases. Titles and abstracts of the retrieved articles were screened using a literature evaluation form. A quality assessment form was developed to assess the quality of the included studies. Heterogeneity among the studies was assessed. Pooled data were analysed using meta‐analytical methods and comparisons between different algorithms were performed. Results Of 765 articles retrieved, 30 studies were eligible for meta‐analysis. Pooled sensitivity for artificial intelligence was slightly higher than for dermoscopy (91% vs. 88%; P = 0·076). Pooled specificity for dermoscopy was significantly better than artificial intelligence (86% vs. 79%; P < 0·001). Pooled diagnostic odds ratio was 51·5 for dermoscopy and 57·8 for artificial intelligence, which were not significantly different (P = 0·783). There were no significance differences in diagnostic odds ratio among the different dermoscopic diagnostic algorithms. Conclusions Dermoscopy and artificial intelligence performed equally well for diagnosis of melanocytic skin lesions. There was no significant difference in the diagnostic performance of various dermoscopy algorithms. The three‐point checklist, the seven‐point checklist and Menzies score had better diagnostic odds ratios than the others; however, these results need to be confirmed by a large‐scale high‐quality population‐based study.     

Ultra-high-frequency ultrasound and machine learning approaches for the differential diagnosis of melanocytic lesions

Malignant melanoma (MM) is one of the most dangerous skin cancers. The aim of this study was to present a potential new method for the differential diagnosis of MM from melanocytic naevi (MN). We examined 20 MM and 19 MN with a new ultra-high-frequency ultrasound (UHFUS) equipped with a 70 MHz linear probe. Ultrasonographic images were processed for calculating 8 morphological parameters (area, perimeter, circularity, area ratio, standard deviation of normalized radial range, roughness index, overlap ratio and normalized residual mean square value) and 122 texture parameters. Colour Doppler images were used to evaluate the vascularization. Features reduction was implemented by means of principal component analysis (PCA), and 23 classification algorithms were tested on the reduced features using histological response as ground-truth. Best results were obtained using only the first component of the PCA and the weighted k-nearest neighbour classifier; this combination led to an accuracy of 76.9%, area under the ROC curve of 83%, sensitivity of 84% and specificity of 70%. The histological analysis still remains the gold-standard, but the UHFUS images processing using a machine learning approach could represent a new non-invasive approach.     

Algorithmic reproduction of asymmetry and border cut-off parameters according to the ABCD rule for dermoscopy

BACKGROUND: Semiquantitative algorithms were applied to dermoscopic images to improve the clinical diagnosis for melanoma. OBJECTIVE: The aim of the study was to develop a computerized method for automated quantification of the 'A' (asymmetry) and 'B' (border cut-off) parameters, according to the ABCD rule for dermoscopy, thus reproducing human evaluation. METHODS: Three hundred and thirty-one melanocytic lesion images, referring to 113 melanomas and 218 melanocytic nevi, acquired by means of a digital videodermatoscope, were considered. Images were evaluated by two experienced observers and by using computer algorithms developed by us. Clinical evaluation of asymmetry was performed by attributing scores to shape asymmetry and asymmetry of pigment distribution and structures, whereas computer evaluation of shape and pigment distribution asymmetries were based on the assessment of differences in area and lightness in the two halves of the image, respectively. Borders were evaluated both by clinicians and by the computer, by attributing a score to each border segment ending abruptly. Differences between nevus and melanoma values were evaluated using the chi-square test, while Cohen's Kappa index for agreement was employed for the evaluation of the concordance between human and computer. RESULTS: Pigment distribution asymmetry appears the most striking parameter for melanoma diagnosis both for human and for automated diagnosis. A good concordance between clinicians and computer evaluation was achieved for all asymmetry parameters, and was excellent for border cut-off evaluation. CONCLUSIONS: These algorithms enable a good reproduction of the 'A' and 'B' parameters of the ABCD rule for dermoscopy, and appear useful for diagnostic and learning purposes.     

Improvement of malignant/benign ratio in excised melanocytic lesions in the 'dermoscopy era': a retrospective study 1997-2001

BACKGROUND: Because of the many limitations of studies based on the diagnostic setting of excised lesions, the impact of dermoscopy (epiluminescence microscopy, dermatoscopy) in melanoma screening during practice remains to be established. OBJECTIVES: We assumed that effects of the use of dermoscopy on some indicators of diagnostic performance in melanoma screening should be traceable retrospectively; therefore, we analysed the impact of routine dermoscopy use on the malignant/benign ratio in excised melanocytic lesions. METHODS: Preoperative and histological diagnosis of 3053 melanocytic lesions [319 melanomas (10.4%)] consecutively diagnosed and excised at the Department of Dermatology, University of Florence in the period 1997-2001 inclusive were retrieved. Six dermatologists who selected the lesions to excise and who performed preoperative diagnosis were divided into two groups according to their use of dermoscopy in routine activity (n = 2 dermoscopy users and n = 4 nonusers). The study period was divided into a predermoscopy period (1997), a shift phase (1998) and a dermoscopy period (1999-2001). RESULTS: During the study period, the malignant/benign ratio improved in dermoscopy users only (from 1 : 18 to 1 : 4.3, P = 0.037). No significant difference was found for nonusers (from 1 : 11.8 to 1 : 14.4). Dermoscopy users were more likely to have a melanoma diagnosed within a series of excised lesions than nonusers, even taking into account potential confounders such as sex, age and study period by means of multivariate analysis (odds ratio 1.55, 95% confidence interval 1.17-2.01). The percentage of 'problem' naevi (naevi with architectural disorder with or without cytological atypia and Spitz or Reed naevi) over the total number of excised lesions was higher in dermoscopy users than in nonusers (year 2001, 51.6% vs. 40.9%, P = 0.014). Similar findings were obtained after exclusion from the data set of lesions excised for cosmetic reasons. CONCLUSIONS: The adoption of dermoscopy in routine melanoma screening is followed by an improvement of the malignant/benign ratio in excised lesions, suggesting a more appropriate selection of pigmented lesions referred to surgery. Because of the possible limitations of a retrospective study design, future confirmation of this finding by means of a prospective, randomized study is advisable. The introduction of dermoscopy in routine practice may have major implications in large-scale melanoma screening with cost savings and a reduction of the dermosurgery workload.     

The impact of dermoscopy on the management of pigmented lesions in everyday clinical practice of general dermatologists: a prospective study

Background Dermoscopy greatly improves the clinical diagnosis of pigmented lesions. Few studies have investigated, however, how dermoscopy is guiding management decisions in everyday clinical practice. In addition, most studies have been performed in the setting of dermoscopy experts working in pigmented lesion clinics. Objectives To assess the impact of dermoscopy on clinical diagnosis and management decisions for pigmented lesions in everyday practice of general dermatologists. Methods We performed a prospective study in general dermatology clinics in community hospitals run by dermatologists with intermediate dermoscopy experience and expertise. Each clinician independently included suspicious lesions from consecutive patients. Pre‐ and postdermoscopy diagnoses and management decisions were recorded. Pathology was used as reference diagnosis. Results In total, 209 suspicious lesions were included in the study by 17 dermatologists. Fourteen lesions were histologically proven in situ or invasive malignant melanomas. Based on clinical diagnoses, dermoscopy improved sensitivity from 0·79 to 0·86 (P = 1·0). All 14 melanomas were intended to be excised based on naked eye examination alone, independent of dermoscopic evaluation. Specificity increased from 0·96 to 0·98 (P = 0·22). Dermoscopy resulted in a 9% reduction of the number of excisions. Conclusions Dermoscopy reduced the number of excisions, but did not improve the detection of melanomas. Our results suggest that in everyday clinical practice of general dermatologists the main contribution of dermoscopy is a reduction of unnecessary excisions.     

Clinical, dermoscopy and histological correlation study of melanotic pigmentations in excision scars of melanocytic tumours

BACKGROUND: Melanotic pigmentations in scars consecutive to the excision of melanocytic tumours can be secondary to a reactive phenomenon related to the scar tissue or to a recurrence of the melanocytic lesion excised in the first case. Recurrent naevi may sometimes adopt unusual features that make them difficult to differentiate from a melanoma. OBJECTIVES: To describe the clinical, dermoscopic and histological features of melanotic pigmentations in scars consecutive to the excision of melanocytic tumours, and to correlate the histological diagnosis with the dermoscopic features. METHODS: This was a prospective cohort study using macrophotography, dermoscopy and histopathological study. Ninety-five melanotic pigmentations (77 patients) in scars secondary to the excision of melanocytic tumours were prospectively collected in the Department of Dermatology at the Instituto Valenciano de Oncología in Valencia, Spain. Histopathological study was performed in 57 scars. RESULTS: Thirteen dermoscopic structures were identified. Four criteria allowed a differentiation between reactive and specific melanocytic pigmentations. Presence of globules and presence of heterogeneous pigmentation were features associated with specific melanocytic pigmentations (P < 0.0001). Presence of a regular network and presence of streaks were more frequently found in reactive pigmentations (P = 0.023 and 0.026, respectively). CONCLUSIONS: Dermoscopic examination of melanotic pigmentations in excision scars of melanocytic tumours provides useful information about the origin of that pigmentation. Based on such information, recurrent naevi can be differentiated from reactive pigmentations in most cases. Excision and histopathological diagnosis continue to be imperative in some cases of recurrent naevi with atypical clinical features.     

Clinical usefulness of dermoscopy in the management of lentigo maligna melanoma treated with topical imiquimod: A case report

The importance of dermoscopy for diagnosing lentigo maligna melanoma (LMM) is well known. More recently, dermoscopy has been proposed as a useful tool also for the treatment choice and monitoring. Herein, we present an 87‐year‐old woman, who was successfully treated with imiquimod 5% cream after surgical persistence of residual LMM and for whom dermoscopy was helpful to assist diagnosis and assess tumor persistence after surgery and its response to topical treatment with imiquimod.     

Clinically equivocal melanocytic skin lesions with features of regression: a dermoscopic-pathological study

BACKGROUND: Benign melanocytic skin lesions may be difficult to differentiate from melanoma both clinically and dermoscopically. One of the most confounding dermoscopic features, commonly seen in melanoma but in our experience also in melanocytic naevi, is represented by the so-called blue-white structures (BWS). OBJECTIVES: To evaluate diagnostic significance and histopathological correlates of BWS seen by dermoscopy in a series of clinically equivocal melanocytic skin lesions that were excised. METHODS: Patients were recruited from six specialized pigmented lesion clinics in Austria, Italy and Spain over a period of 9 months. All consecutive patients showing one or more melanocytic lesions with BWS, but not classified as melanoma dermoscopically, were included. Each lesion was photographed clinically and dermoscopically. All images were reviewed by one of us and the degree, type and location of BWS evaluated for each lesion. A panel of four experienced dermatopathologists independently reviewed all specimens for diagnosis and one of them evaluated presence and degree of melanosis and/or fibrosis. The main outcome measures were the percentage and histopathological correlates of lesions with different degree, type and location of BWS. RESULTS: All included lesions with BWS (n = 158) showed partial or focal regression histopathologically. One hundred and thirty-five (85.4%) lesions were diagnosed as melanocytic naevi (complete histopathological interobserver agreement), whereas 23 (14.6%) were defined as equivocal because at least one of four pathologists diagnosed the given lesion as melanoma. Only one lesion was diagnosed as melanoma by all four pathologists. The majority of naevi exhibited blue areas (84.4%) with a central distribution (57%) and involving < 50% of the lesion surface (89.6%). By contrast, 78.3% of equivocal lesions revealed a combination of white and blue areas with an irregular distribution (60.9%) and involving > 50% of the lesion surface (47.8%). CONCLUSIONS: Using degree and type of BWS, an algorithm was constructed that can be applied for the management of lesions exhibiting dermoscopic features of regression.     

Value of the clinical history for different users of dermoscopy compared with results of digital image analysis

BACKGROUND: The clinical history of a given pigmented lesion could influence the therapeutic decision. Teledermatology and automated image analysis also hold great potential for revolutionizing dermatology services. AIM: The aim of this retrospective study was to evaluate the diagnostic accuracy of users with different experiences in dermoscopy with and without information about patients and their history compared with classification by an automated analysing system. SETTING: One hundred and fifty-seven dermoscopic images of pigmented lesions, taken and proved by histopathology at the Pigmented Lesions Clinic of the Department of Dermatology of the University Tuebingen, Germany, were included. METHODS: All images were viewed by three investigators with different experience: excellent (A), average (B) and beginner (C). In the first dermoscopic classification, no information was available. After 3 months the same images were once more classified by the three investigators, now with the information about the patients and their history. The melanocytic lesions were tested by the Tuebinger Mole Analyser. RESULTS: For user A the sensitivity, specificity and diagnostic accuracy revealed no improvement on including the history (81.3% to 84.4%, 94.6% to 92.3% and 92.0% to 90.7%), whereas user B clearly improved his results (75.0% to 87.5%, 76.9% to 88.5% and 76.5% to 88.3%). No change in the sensitivity was seen by user C (84.4%), but there was a clear improvement in the specificity (69.2% to 87.7%) and diagnostic accuracy (72.2% to 87.0%). Using the computer algorithm, a sensitivity of 100%, a specificity of 76.9% and a diagnostic accuracy of 81.9% were achieved. CONCLUSIONS: The study revealed results relevant to the use of dermoscopy: (1) continuing dermoscopic education influences the diagnostic accuracy; (2) the history is helpful for averaged users and beginners in dermoscopy; (3) digital image analysis has the highest sensitivity, but a lower specificity compared to the clinicians; and (4) digital dermoscopy could be used for store-and-forward systems in teledermoscopy.     

Comparison of dermatoscopic diagnostic algorithms based on calculation: The ABCD rule of dermatoscopy,the seven‐point checklist,the three‐point checklist and the CASH algorithm in dermatoscopic evaluation of melanocytic lesions

Dermatoscopic analysis of melanocytic lesions using the CASH algorithm has rarely been described in the literature. The purpose of this study was to compare the sensitivity, specificity, and diagnostic accuracy rates of the ABCD rule of dermatoscopy, the seven‐point checklist, the three‐point checklist, and the CASH algorithm in the diagnosis and dermatoscopic evaluation of melanocytic lesions on the hairy skin. One hundred and fifteen melanocytic lesions of 115 patients were examined retrospectively using dermatoscopic images and compared with the histopathologic diagnosis. Four dermatoscopic algorithms were carried out for all lesions. The ABCD rule of dermatoscopy showed sensitivity of 91.6%, specificity of 60.4%, and diagnostic accuracy of 66.9%. The seven‐point checklist showed sensitivity, specificity, and diagnostic accuracy of 87.5, 65.9, and 70.4%, respectively; the three‐point checklist 79.1, 62.6, 66%; and the CASH algorithm 91.6, 64.8, and 70.4%, respectively. To our knowledge, this is the first study that compares the sensitivity, specificity and diagnostic accuracy of the ABCD rule of dermatoscopy, the three‐point checklist, the seven‐point checklist, and the CASH algorithm for the diagnosis of melanocytic lesions on the hairy skin. In our study, the ABCD rule of dermatoscopy and the CASH algorithm showed the highest sensitivity for the diagnosis of melanoma.