Vol. 28. No. 3


The visual nature of dermatology has always lent itself perfectly to the plethora of available imaging techniques. The rapid expansion of visual technologies has provided further insight into the subtleties of our specialization. This issue of Seminars in Cutaneous Medicine and Surgery titled “Dermoscopy and Recently Developed Imaging Techniques” has been collated to demonstrate the broad scope of imaging techniques used within the field and their application in both clinical and research settings. As the title suggests, the core of this issue revolves around the art of dermoscopy and the relevance of its application in early detection of melanoma in addition to various other melanocytic and nonmelanocytic cutaneous neoplasms. Indeed, the morphologic classification based on dermoscopic features continues to evolve and enable more efficient monitoring, particularly of melanocytic lesions over time, in addition to refined aspects of clinico-pathologic correlation. The articles in this issue, all written by world-renowned experts in the field, outline the existing guidelines of dermoscopy in this regard as well as the current and future research focus of this technique. Perhaps one of the more recently conspicuous advances in dermoscopic evaluation has been the rise of teledermoscopy, which has facilitated the worldwide exchange of knowledge and expertise in dermatology and dermatopathology and provided the platform for second opinion. Technological advancement is perhaps most evident in regard to the imaging capacity of new generation cellular phones, which have quickly become almost ubiquitous among modern developed societies. Without a doubt, the potential feasibility of such an application is worth due consideration and an overview of its potential is also provided. While dermoscopy has cemented its place clinically in the superficial morphologic evaluation of pigmented lesions, the diagnostic standard remains to be histopathologic assessment requiring tissue biopsy for confirmation. A relatively new application in dermatology is confocal microscopy, a noninvasive instrument capable of generating horizontal planar sections of the epidermis and dermis in vivo. This tool, offering high-contrast cellular resolution images, will impact greatly on the current methods of clinical diagnosis of melanocytic lesions and nonmelanocytic skin cancers. The research and clinical applications of this exciting method will also be detailed presently. Other in vivo techniques, namely multiphoton laser scanning microscopy and optical coherence tomography, will also be outlined and help to complete the picture of the range of imaging techniques on the horizon within dermatology. While still in their early stages of potential application, the modern imaging techniques hold great potential within the field of dermatology. When combined with the current knowledge, morphologic evaluation may revolutionize the validity of diagnostic assessment. Furthermore, it is without a doubt that dermoscopy continues to provide dermatologists with a deepened insight into the many faces of pigmented skin lesions, strengthened by the continued refinement of techniques. It is with this spirit that this issue on dermoscopy and recently developed imaging techniques has been written.

Dermoscopy—The Ultimate Tool for Melanoma Diagnosis

Antonia Martino, MD | Gerardo Ferrara, MD | Giuseppe Argenziano, MD | Iris Zalaudek, MD | Karin Di Nola, MD | Sabrina Francione, MD

“We are beginning to move away from clinicopathologic diagnosis into an era of clinicoimaging
diagnosis.” This vision became a fact, as the dermatoscope represents nowadays
the dermatologist stethoscope. This is not only because dermoscopy reveals a new and
fascinating morphologic dimension of pigmented and nonpigmented skin tumors, but also
because it improves the recognition of a growing number of skin symptoms in general
dermatology. Melanoma detection remains the most important indication of dermoscopy
and in melanoma screening the aim of dermoscopy is to maximize early detection while
minimizing the unnecessary excision of benign skin tumors. In the last few years, 3
meta-analyses and 2 randomized studies have definitely proven that dermoscopy allows
improving sensitivity for melanoma as compared to the naked eye examination alone. This
is the consequence of at least 3 issues: first, the presence of early dermoscopy signs that
are visible in melanoma much before the appearance of the classical clinical features;
second, an increased attitude of clinicians to check more closely clinically banal-looking
lesions; third, an improved attitude of clinicians to monitor their patients.
Semin Cutan Med Surg 28:142-148 © 2009 Elsevier Inc. All rights reserved.


The Morphologic Universe of Melanocytic Nevi

Gerardo Ferrara, MD | Giovanni Docimo, MD | Giuseppe Argenziano, MD | Imma Savarese, MD | Iris Zalaudek, MD | Manuela Manzo, MD

Different types of nevi do exist in relation to their epidemiology, morphology, evolution, and
associated melanoma risk. The introduction of dermoscopy opened a new dimension of the
morphologic universe of nevi and allowed clinicians to observe colors and structures within
nevi that are otherwise not visible to the unaided eye. Because most of these colors and
structures correspond to well-defined histopathologic correlates, dermoscopy enables
clinicians to date to more precisely predict the histopathology diagnosis and thereby
improve on their clinical diagnostic accuracy. Besides the diagnostic impact, the in vivo
observation of thousands of nevi using dermoscopy and digital dermoscopic follow-up has
opened new understanding about the evolution of nevi and factors influencing the nevus
pattern. In consequence, a new nevus classification has been proposed, subdividing nevi
into 7 categories, which are as follows: (1) globular/cobblestone nevi, (2) reticular nevi, (3)
starburst nevi, (4) homogeneous blue nevi, (5) nevi on special body sites, (6) nevi with
special features, and (7) and unclassifiable melanocytic proliferations. This article provides
an overview on the morphologic classification of nevi and the factors influencing the nevus
Semin Cutan Med Surg 28:149-156 © 2009 Elsevier Inc. All rights reserved.


Dermoscopic-Pathologic Correlation: Apropos of Six Equivocal Cases

Caterina M. Giorgio, MD | Gerardo Ferrara, MD | Giuseppe Argenziano, MD | Harald Kittler, MD | Iris Zalaudek, MD

The increasing use of dermoscopy in preoperative diagnosis of melanocytic skin
neoplasms is impacting on routine histopathology to a relevant extent. We herein
present the dermoscopic-pathologic features of 6 cases of histopathologically controversial
melanocytic skin neoplasms. By illustrating these cases, we emphasize at least
3 different fields of interest for a combined (clinico-)dermoscopic-pathologic diagnostic
approach, namely, information about the evolution of lesions; detection of gross
sampling errors; definition of peculiar clinicopathologic entities. The theoretic and
practical aspects of a close interaction among dermoscopists and histopathologists are
itemized in detail.
Semin Cutan Med Surg 28:157-164 © 2009 Elsevier Inc. All rights reserved.


Dermoscopy Research—An Update

A.A. Marghoob, MD | Harold S. Rabinovitz, MD | Ralph P. Braun, MD

Dermoscopy increases the clinician’s diagnostic accuracy by as much as 30% over that of
unaided visual clinical inspection alone and has been confirmed in 3 separate evidencebased
publications using a meta-analysis of the literature. It can be viewed as an in vivo
bridge between clinical morphology and histopathology. This “bridge” has provided clinician
researchers with many new insights into morphology and tumor biology. In this article,
we provide the reader with an overview of the different aspects of dermoscopy as a
research tool. We cover different aspects, such as the new equipment, new structures, the
importance of blood vessels, etc.
Semin Cutan Med Surg 28:165-171 © 2009 Published by Elsevier Inc


Reflectance Confocal Microscopy—State-of-Art and Research Overview

Armin Gerger, MD | Elisabeth M.T. Wurm, MD | Erika Richtig, MD | Josef Smolle, MD | Rainer Hofmann-Wellenhof, MD | Silvia Koller, MD | Verena Ahlgrimm-Siess, MD

Reflectance confocal microscopy (RCM) enables in vivo imaging of human skin at a quasi
histologic resolution. The black-and-white RCM images show horizontal sections of the
skin, at a maximum depth of 350 m. To date, the RCM features of a significant number of
skin conditions have been described. The main focus of the research community investigating
RCM, however, lies on describing and diagnosing melanocytic skin lesions. Taking
into account all RCM studies dealing with diagnostic accuracy in melanocytic skin lesions,
sensitivity and specificity of approximately 90% and 86% could be found. Improvement of
diagnostic accuracy, improved assessment of dermoscopic-histologic correlation, in vivo
biopsy side selection, surgical margin assessment, and response control of conservative
therapies in skin diseases are some of the major advantages of this novel imaging method.
Additionally, RCM holds inherent potential for teledermatologic application and automated
image analyzing. This article describes morphologic features of diverse skin lesions and
features of “normal skin,” summarizes diagnostic advances of RCM, compares studies
dealing with diagnostic applicability, and discusses further research goals of this exciting
new imaging technique.
Semin Cutan Med Surg 28:172-179 © 2009 Elsevier Inc. All rights reserved.