Dermoscopy. Synonyms. Dermoscopy. Definition. Dermoscopy opens up a world of colour and structure that can t be seen with the naked eye
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1 Synonyms Dermoscopy Australasian College of Dermatologists G.P Training Module Dermoscopy Dermatoscopy Epiluminescence microscopy Skin surface microscopy Incident light microscopy Oil immersion microscopy In vivo cutaneous surface microscopy Definition Non-invasive in vivo technique 10X magnification & bright illumination Transparent medium or Polarised filter minimise skin surface reflectance Polarised filter Dermoscopy Allows visualisation of subsurface structures and colours not readily observed with naked eye examination Epidermis Dermo-epidermal junction Superficial dermis Uniform pigment network Fades at periphery Dermoscopy opens up a world of colour and structure that can t be seen with the naked eye Robert Johr M.D. Robert Johr M.D. Dx = Benign junctional naevus 1
2 Atypical pigment network Pseudopods Peripheral black dots Blue-grey veil Brief history of dermoscopy 1893 Diaskopie (Unna) 1916 Binocular dermatoscope (Zeiss) 1958 First portable dermoscope 1989 First consensus meeting 1991 First atlas (Kreusch) 2001 Polarised light dermoscopy Dx = Superficial spreading melanoma *Almost 500 peer-reviewed publications on dermoscopy in the last 5 years Diagnostic algorithms 1987 Pattern Analysis (Pehamberger) 1994 ABCD Method (Stolz) 1996 Menzies Method point checklist (Argenziano) point checklist (Soyer) 2007 C.A.S.H algorithm (Kopf) Value of dermoscopy Diagnostic aid for both: benign and malignant lesions pigmented and non-pigmented lesions Diagnosis of early melanoma Differentiation of melanoma from benign pigmented lesions e.g. naevi, seborrhoeic keratoses etc Acral skin & nail apparatus also Value of dermoscopy Improves diagnostic accuracy 10-27% improvement in Dx of melanoma Improves benign to malignant ratio Reduces need for biopsy *Most valuable in diagnosing benign lesions that may otherwise require biopsy e.g. dark junctional naevi, angiomas, seborrhoeic keratoses Value of dermoscopy Improves clinical efficiency Builds clinical confidence Bridges clinical exam & pathology Specialist and primary care setting *Value is significantly influenced by observer experience Menzies SW & Zalaudek I. Why perform dermoscopy? [editorial] Arch Dermatol 2006;142:
3 Limitations of dermoscopy Sequential monitoring Very early melanoma Featureless melanoma Amelanotic melanoma Nodular or primarily dermal lesions Extremely dark lesions Some formal training optimal Learning curve to overcome Histopathology still gold standard Digital dermoscopic monitoring enables detection of melanomas very early in their evolution before they have developed typical clinical characteristics Menzies SW et al. Arch Dermatol 2001;137: Haenssle HA et al. J Invest Dermatol 2006;126: Novel uses Diffuse & regular dotted vessels Inflammatory dermatoses e.g psoriasis Infections e.g scabies Nail fold vasculature e.g scleroderma Hair shaft disorders e.g monilethrix Nail plate discolouration e.g. subungual haemorrhage Dx = Chronic plaque psoriasis Delta or triangle Dx = Scabies infestation Elements Hand-held monocular instrument Similar to otoscope L.E.D illumination Polarised or non-polarised light Contact (wet) or non-contact (dry) Immersion fluid for contact dermoscopy Camera for documentation Digital-ELM (D-ELM) systems for archival 3
4 Colours Black Dark brown Light brown Grey-blue Steel blue Red White Yellow Stratum corneum Superficial epidermis Deep epidermis Papillary dermis Reticular dermis Vasculature Depigmentation or scar Hyperkeratosis or sebaceous glands Polarised light dermoscopy Arborising telangiectasia in sharp focus Structureless pink matrix Advantages No immersion fluid necessary Non-contact (most DermLites) Quicker Vascular structures Milky-red areas seen more easily Dx = Nodular BCC Milky pink/red areas Inverse network Atypical vessels Faint tan pigmentation Polarised light dermoscopy Disadvantages Blue-grey veil Regression structures Milia-like cysts seen less easily Dx = Hypomelanotic invasive SSM 4
5 Blue-grey veil Dysplastic naevus Macro NPCD Blue-grey veil PCD PNCD NPCD = non polarised contact dermoscopy e.g. Heine Delta-20 PCD = polarised contact dermoscopy e.g. DermLite Fluid-II PNCD = polarised non-contact dermoscopy e.g. DermLite Pro Dx = Invasive SSM Benvenuto-Andrade C et al Arch Dermatol 2007;143: Blue-grey dots or peppering Regression structures Congenital naevus Macro NPCD Regression structures PCD PNCD Dx = Invasive SSM with regression Benvenuto-Andrade C et al Arch Dermatol 2007;143: Milia-like cysts Seborrhoeic keratosis Macro NPCD Milial cysts Comedo-like openings PCD PNCD Dx = Seborrhoeic keratosis Benvenuto-Andrade C et al Arch Dermatol 2007;143:
6 Which instrument? Heine Delta-20 Non-Polarised dermoscopy Welch-Allyn Episcope DermoGenius Polarised dermoscopy DermLite Heine Delta 20 + Nikon Coolpix 4500 Cost Handheld dermoscopes $AUD Basic DermLites (polarised) cheapest DermLite Fluid II + Sony Cybershot DSC-W70 6
7 Computerised image analysis SolarScan (Polartechnics/C.S.I.R.O) MoleMax III (University of Vienna) Fotofinder Digital dermoscopy Macroscopic imaging Data storage and retrieval Monitoring Diagnostic support SolarScan MoleMax-III Computerised systems Still require clinical judgement Still require dermoscopy skills Quality of imaging not necessarily superior to handheld instruments Which immersion fluid? Oil e.g. olive, mineral, Nozoil *messy to apply and stain clothes Alcohol or aqueous-based e.g. Codan *easier to apply, evaporate quickly Gel e.g. KY gel, ultrasound gel *don t run, preferable near eyes or on nail plates Handling tips 1. Consider dry dermoscopy when examining a large number of lesions 2. Move to wet dermoscopy if uncertain 3. Ensure good contact between the glass plate and the skin surface 4. Avoid excess pressure (compresses and obscures vessels) 7
8 Handling tips 5. Position the patient for comfortable examination 6. The eye must be close to the lens 7. Focus the lens where applicable 8. Be liberal with immersion fluid Dermoscopic terminology Pigment network Typical = regular calibre lines & holes, fades at periphery Atypical = non-uniform, ends abruptly, broadened Inverse = white lines, brown/red holes Pseudonetwork = diffuse facial pigmentation interrupted by follicular openings (unique to facial skin) Dermoscopic terminology Pigment network typical 2. atypical 3. inverse 4. pseudonetwork Melanin in KC & MC outlining rete ridges Epidermal suprapapillary plates = Network lines = Network holes Terminology cont d Dots <0.1mm, brown, black, blue or grey Globules >0.1 mm, brown, black or red Blotches brown or black, structureless Peppering fine blue-grey granules of melanin Pseudopods peripheral finger-like projections with bulbous endings Radial streaming peripherally radiating lines Branched streaks alternate term for radial streaming and or pseudopods Blue-grey veil confluent bluish pigmentation with overlying white ground-glass haze Blue-grey veil Blue-white veil Blue-grey veil Most significant dermoscopic finding of invasive melanoma 51% sensitivity 97% specificity synonymous terms Menzies SW et al. Melanoma Res 1996;6:
9 Compact orthokeratosis Terminology cont d radial streaming / branched streaks blue-grey veil globules blotches Heavily pigmented melanocytes pseudopods dots peppering Terminology cont d Terminology cont d Regression structures Structureless areas Cobblestone globules Starburst pattern Parallel patterns scar-like depigmentation with peppering regions devoid of structures crowded polygonal globules symmetrical and radially streaks parallel pigmentation within furrows or ridges on acral skin Cobblestone globules Regression structures Terminology cont d Starburst pattern Patterns on acral skin A. Parallel furrow B. Parallel furrow and globules C. Parallel furrow (thick) D. Parallel globules E. Lattice F. Lattice G. Fibrillar or filamentous H. Atypical I. Homogenous J. Globular K. Reticular L. Parallel Ridge Mulvehy J, Puig S et al Arch Dermatol
10 Vascular terminology Vessels (cont d) Lacunes large red-blue-black globular structures lacunes hairpin Hairpin elongated and looped Dotted small pin sized vessels Comma comma or tadpole-shaped Glomerular highly convoluted resembling the glomerular apparatus of the kidney glomerular dotted comma Argenziano et al. Arch Dermatol 2004 Vessels (cont d) Vessels (cont d) Coronal Corkscrew peripheral and wreath-like irregular and thickly coiled arborizing Arborizing Polymorphous branching, variable luminal diameter multiple morphologies including comma, dotted, corkscrew, glomerular, linear irregular etc coronal corkscrew 2 step algorithm a. Pigmented lesions Melanocytic Pigmented lesion Non-melanocytic Benign Malignant ABCD rule 7 point checklist Menzies method 3 point checklist 10
11 Step 1 Classify as melanocytic or otherwise (facial skin) pigmentation (acral skin) Uniform pigment network Fades at periphery Dx = Benign junctional naevus Atypical pigment network Symmetrically distributed black dots Atypical pigment network Black dots & blotches Dx = Junctional naevus Dx = Dysplastic naevus Inverse network Atypical pigment network Multiple colours Peripheral brown dots Pseudopods Blue-grey veil Eccentric inverse network Typical pigment network Multicomponent pattern Regression structures Polymorphic vessels Dx = 0.7 mm Level II SSM Image courtesy of Dr Greg Canning Dx = 0.8 mm Level III naevoid melanoma Image courtesy of Dr Ben Cook 11
12 Inverse network Milky pink areas Atypical vessels Faint tan pigmentation Inverse network Marginal typical pigment network Multicomponent Multiple colours Atypical vessels Horn cysts Dx = Hypomelanotic invasive SSM Dx = Hypomelanotic LIII 1.2mm SSM Pseudonetwork Moth eaten border Lacy peripheral pigment network Central scar-like area Dx = Solar lentigo (facial) Dx = Dermatofibroma *Despite having a pigment network, dermatofibromas are non-melanocytic & are one exception to this rule* Diffuse brown globules Symmetry of structures Peripheral brown globules Central reticular network Dx = Benign compound naevus Dx = Evolving benign compound naevus 12
13 Branched streaks/radial streaming Blue-grey veil Multiple colours Black blotches Branched streaks/radial streaming Blue-grey veil Multiple dots Scar-like depigmentation Regression structures Multiple colours Dx = Invasive SSM Dx = Invasive SSM Radially arranged streaks & pseudopods Starburst pattern Diffuse homogenous blue pigmentation Dx = Spitz naevus Dx = Blue naevus Parallel furrow pattern Parallel lattice pattern Dx = Benign acral naevus Dx = Benign acral naevus 13
14 Parallel furrow pattern Fibrillar Furrow Lattice Dx = Benign acral naevus Miyazaki JAAD 2005;53:230-6 Patterns on acral skin A. Parallel furrow B. Parallel furrow and globules C. Parallel furrow (thick) D. Parallel globules E. Lattice F. Lattice G. Fibrillar or filamentous H. Atypical I. Homogenous J. Globular K. Reticular L. Parallel Ridge RIDGE melanoma FURROW benign naevus Mulvehy J, Puig S et al Arch Dermatol 2004 Ridge pattern = consider melanoma Look for eccrine gland openings Non-melanocytic lesions defying the 2 step rule Network-like structures Seborrhoeic keratosis, solar lentigo, dermatofibroma, accessory nipple Globules Seborrhoeic keratosis, pigmented BCC dermatofibroma, talon noir (subcorneal haemorrhage) Streaks Seborrheoic keratosis, pigmented BCC Homogenous blue Kaposi sarcoma, radiation tattoo, pigmented BCC Scope et al. Dermatol Surg 2006;32:
15 If a lesion lacks positive melanocytic & non-melanocytic criteria, then by default it should be deemed to be melanocytic. melanocytic criteria * non-melanocytic criteria In particular featureless melanoma should be considered. dermoscopic grey-zone *?featureless melanoma Atypical/polymorphous vessels?faint tan pigment Horn cysts Biopsy scar 2 step algorithm Pigmented lesion Melanocytic Non-melanocytic Dx = Amelanotic lentigo maligna Benign Malignant ABCD rule 7 point checklist Menzies method Pattern analysis 3 point checklist Melanocytic or not? Non-melanocytic Argenziano G et al. J Am Acad Argenziano Dermatol et 2003;48: al JAAD
16 Seborrhoeic keratosis Seborrhoeic keratosis comedo-like openings hairpin vessels fat fingers network-like structures milia-like cysts fingerprinting ridges and fissures (crypts) moth eaten & sharply demarcated border Fat fingers Ridges and fissures Network-like structures Comedo-like openings Fissures and crypts Fat fingers Milia-like cysts Fingerprinting Dx = Seborrhoeic keratosis Dx = Seborrhoeic keratosis Comedo-like openings Absent network Abrupt border Ridges and fissures The wobble sign Dermal naevus wobbles whilst seb K won t Dx =Seborrhoeic keratosis Braun RP et al. Arch Dermatol 2000;136:
17 pseudonetwork Solar lentigo Moth eaten border Fingerprinting moth eaten border finger-printing network-like structures Dx = solar lentigo Moth eaten border Fingerprinting Pseudonetwork Pigmented solar keratosis Overlapping features with lentigo maligna Lacks specific dermoscopic features Pseudonetwork broken up Annular-granular structures Rhomboidal structures Dx = solar lentigo Zalaudek I et al. JAAD 2005;53: Moth eaten border Broken up pseudonetwork Sharp cut-off Benign lichenoid keratosis peppering finger-printing Dx = pigmented solar keratosis 17
18 Fingerprinting Peppering blue-grey ovoid nests Pigmented BCC leaf-like structures spoke-wheel areas blue-grey globules Dx = benign lichenoid keratosis Leaf-like structures Arborising telangiectasia Blue-grey ovoid nests Spoke wheel structures Network-like structures Dx = Pigmented BCC Dx = Pigmented BCC Spoke wheel structures Network-like structures Pigmented BCC ulceration arborising telangiectasia Dx = Pigmented BCC 18
19 Arborising telangiectasia Blue grey ovoid nest Arborising telangiectasia Ulceration Dx = Pigmented BCC Dx = Basal cell carcinoma Haemangioma Red & purple lacunes red-blue lacunes Dx = Haemangioma Red lacunes Dermatofibroma variable central dotted vessels central scar Dx = Haemangioma delicate peripheral lacy network 19
20 Lacy peripheral pigment network Central scar-like area Step 2 Once the lesions has been defined as melanocytic, classify as benign or malignant Remember, if you can t confidently identify the lesion as benign some form of active intervention should be taken Dx = Dermatofibroma Melanocytic Benign 2 step algorithm Pigmented lesion Malignant Non-melanocytic ABCD rule 7 point checklist Menzies method Pattern analysis 3 point checklist Dermoscopy algorithms 1990 First Consensus meeting 22 unique patterns and structures 8 variations on the pigment network Cumbersome to learn Algorithms designed to help organise Dermoscopy algorithms Pattern analysis (Pehamberger) ABCD rule (Stolz) Menzies method 7-point checklist (Argenziano) 3-point checklist (Soyer) C.A.S.H algorithm (Kopf) Superior diagnostic efficiency With experience, most will use their instinct based on integrating all the features or gestalt Pattern Analysis Melanocytic lesions are defined by colours and structures Symmetrical distribution benign Benign global patterns Reticular, globular, cobblestone, starburst, homogenous, starburst or parallel Melanoma local features Dots, globules, blotches, radial streaming/pseudopods, regression structures, blue-grey veil, (polymorphic vessels) 20
21 Benign lesions Benign naevus patterns Few colours Architectural order Symmetry of pattern Homogeneity Benign naevi Uniform pigment network Common melanocytic naevi junctional, compound & dermal Blue naevus & combined naevus Spitz naevus Congenital naevus Dysplastic naevus Dx =Benign junctional naevus Uniform pigment network Minor asymmetry of structures Globular pattern Dx = Benign junctional naevus Dx = Benign compound naevus 21
22 Symmetry of structures Peripheral reticular network Patchy central brown globules Faint tan homogenous pigment Peripheral comma-shaped vessels Dx = Benign compound naevus Dx = Benign intradermal naevus Homogenous blue pigment Regular pigment network Focal homogenous blue blotch Dx = Blue naevus Dx = Combined naevus Starburst pattern Symmetric peripheral globules Blue-black colour Symmetry of structures Cobblestone-globular pattern Dx = Spitz naevus Dx = Benign congenital naevus 22
23 Cobblestone-globular pattern Symmetry of structures Blue-brown Peripheral brown globules Central reticular network Dx = Benign congenital naevus Dx = Evolving benign compound naevus Peripheral rim of globules Sign of evolving naevi 80% will show enlargement if followed Not limited to Spitz naevi Acral naevi Fibrillar Furrow Lattice Kittler H et al. Frequency and characteristics of enlarging common melanocytic naevi. JAAD 2000;136: Miyazaki JAAD 2005;53:230-6 Dysplastic naevi Dysplastic naevi May share clinical features (ABCD criteria) with melanoma Risk marker for melanoma Frequently large i.e. diameter 10mm+ Very broad morphologic spectrum Cytological and architectural atypia ranges from mild to severe Can be difficult to distinguish from early melanoma 5 commonest patterns Diffuse reticular Patchy reticular Peripheral reticular + central hypopigmentation Peripheral reticular + central hyperpigmentation Peripheral reticular + central globules 23
24 Dysplastic naevi Disordered network Regression structures Central brown dots At the more atypical end of the spectrum Regression structures Broadened network Abrupt network cut-off Asymmetric pigment pattern Blue-grey veil, pseudopods, radial streaming usually absent Dx = dysplastic naevus Patchy reticular network Peripheral reticular network Patchy inverse network Patchy hypopigmentation Multiple colours Architectural disorder Dx = dysplastic naevus Dx = dysplastic naevus Melanoma Melanoma Multi-coloured Architectural disorder Asymmetrical multi-component patterns with 3+ structures Heterogeneity 24
25 ABCD Rule Asymmetry 2 axes (0-2) x 1.3 Border sharpness (0-8) x 0.1 Colours LB,DB,B,R,W,BG (1-6) x 0.5 Dermoscopic structures (1-5) x 0.5 (dots, globules, structureless, network, branched streaks) TDS <4.75 benign TDS >5.45 malignant * ignores regression + vascular structures * most tedious Menzies method Negative features (presence melanoma) Symmetry of structures Single colour Positive features (any 1 feature = suspicious) B-W veil Multiple colours (5-6) Streaks Pseudopods Scar-like depigmentation Broadened network Dots - brown, black or blue-grey 7 point checklist Major criteria Atypical pigment network Blue-white veil Atypical vascular pattern 3 point checklist Asymmetry of structures Atypical network Blue-white structures Minor criteria Irregular streaks Dots/globules Blotches Regression 2 of 3 features suspect malignancy Score of 3 or more = melanoma C.A.S.H. algorithm Colour (LB, DB, black, red, white, blue) Architectural disorder (none, mild, mod, marked) Symmetry (symmetry in 2 axes, 1 axis, biaxial asymmetry) Homo/heterogeneity (dots/globules, streaks, bwv, regression structures, single colour>10%, polymorphic vessels) Atypical pigment network Pseudopods Peripheral black dots Blue-grey veil Total C.A.S.H. score (TCS) > 8 (melanoma) Dx = Invasive Superficial spreading melanoma 25
26 Multi-component pattern Extensive regression Radial streaming Blue-grey veil Multi-component pattern Regression structures Blue-white veil Radial streaming/pseudopods Scar-like depigmentation Dx = In situ superficial spreading melanoma Dx = Invasive superficial spreading melanoma Blue-white veil Multi-component pattern Regression structures Peripheral dots/globules Atypical pigment network Blue-white veil Multi-component pattern Regression structures Branched streaks Atypical vessels Regression Blue-white veil Dx = Invasive superficial spreading melanoma Dx = 0.4 mm LII SSM Image courtesy of Dr Cliff Rosendahl Focally broadened network Radial streaming Architectural disorder Polymorphic vessels (glomerular, hairpin & comma) Central pseudonetwork Dx = 0.35mm SSM Dx = 2.3 mm LIII amelanotic nodular melanoma 26
27 Remember Is it benign? Menzies two criteria for benignity Symmetry of pattern Single colour 3 point checklist allows one of Asymmetry Atypical pigment network Blue grey structures Which lesions to examine? Assess as many lesions as possible Assess any changed lesion Assess any lesion causing concern Assess any distinct lesions (ugly duckling) Assess all clinically suspicious lesions Bowling J et al. Dermoscopy key points. Dermatology 2007;214:3-5. Which lesions to excise? High risk patient with changed lesion Architectural, shape or colour change Pigmented lesion with extensive regression Dermoscopically equivocal lesions Amelanotic/hypomelanotic lesion with atypical vessels or milky red globules Spitzoid lesions Bowling J et al. Dermoscopy key points. Dermatology 2007;214:3-5. Which lesions to excise? Atypical blue naevi Atypical dermatofibromas Lesions lacking clinico-dermoscopic correlation Presence of inverse network Argenziano G et al. Dermoscopy features of melanoma incognito J Am Acad Dermatol 2007;56: Special locations Face lentigo maligna modified by pseudonetwork Glabrous skin acral lentiginous melanoma parallel ridge pattern Nails subungal melanoma disruption of parallelism Face All pigmented lesions on the face will show a pseudonetwork which is due to follicular openings A reticular net is not seen because the rete ridges are effaced Lentigo maligna (in situ melanoma) has a set of unique dermoscopic features 27
28 Lentigo maligna asymmetric pigmented follicular openings rhomboidal structures pseudonetwork annular-granular pattern Pseudonetwork Annular granular pattern Rhomboidal structures Rhomboidal structures Pseudonetwork Annular granular pattern Fingerprinting Black blotches Dx = Lentigo maligna Dx = Lentigo maligna Pseudonetwork Asymmetric pigmented follicular openings Acral lentiginous melanoma APFO Dx = Lentigo maligna Parallel ridge pattern = probable melanoma Ridges are broader than furrows 28
29 Parallel ridge pattern Nail apparatus melanoma Irregular dermoscopy pattern Broad pigmented band made up of lines of varying pigment, width and spacing Lines may end abruptly Disrupted parallelism Small blood spots not uncommon Nail dystrophy in advanced cases Dx =Acral lentiginous melanoma Braun R et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol 2007;56: Nail apparatus melanoma Nail apparatus melanoma Micro-Hutchinson s sign Disruption of parallelism Disruption of parallelism Braun R et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol 2007;56: Non-pigmented lesions b. Non-pigmented lesions Dermal naevus Non-pigmented BCC Bowen s disease Non-pigmented solar keratosis Sebaceous hyperplasia Hypomelanotic/amelanotic melanoma 29
30 Dermal naevus Faint tan homogenous pigment Peripheral comma-shaped vessels Terminal hairs Milial cysts Comma vessels Dx = Benign intradermal naevus Non-pigmented BCC Light pink background Arborising telangiectasia ulceration shiny-pink background arborising telangiectasia Dx = nodular basal cell carcinoma Light pink background Arborising telangiectasia Bowen s disease (SCC in situ) hyperkeratosis Dx = nodular basal cell carcinoma glomerular & dotted vessels 30
31 Clustered glomerular vessels Non-pigmented solar keratosis Erythema (pink-red pseudonetwork) White-yellow hyperkeratosis Yellow keratotic follicular plugs +/- halo Wavy perifollicular vessels Strawberry appearance in 95% cases Dx = Bowen s disease (SCC in situ) Zalaudek I et al. Br J Dermatol 2006;155:951-6 Yellowish follicular keratotic plugs Sebaceous hyperplasia Pink-red pseudonetwork Strawberry appearance Zalaudek I et al. Br J Dermatol 2006;155:951-6 aggregated yellow globules coronal vessels Aggregated central yellow globules Marginal coronal vessels Hypomelanotic & amelanotic melanoma Great mimic with several variants Nodular melanoma Pseudo-inflammatory Regressed melanoma Dx = Sebaceous hyperplasia 31
32 Dx = Amelanotic nodular melanoma Dx = Dermatitis-like hypomelanotic melanoma Hypomelanotic halo melanoma Woods lamp Dermoscopy Variable pigment network Inverse network Milky-red or pink veil Dispersed atypical vasculature e.g. linear irregular, dotted, hairpin & corkscrew Milky-red globules Regression structures Hypomelanotic melanoma marginal pigment network Marginal pigment network Inverse network Regression structures Milky pink veil milky pink veil inverse network atypical vessels regression structures Dx = 0.4 mm LII hypomelanotic melanoma 32
33 Extensive regression Peripheral brown globules Scattered atypical vessels Acknowledgements Assorted images provided courtesy of Dx = 0.62 mm LII melanoma Associate Professor John Kelly Dr Martin Haskett Dr Ian McColl Dr Cliff Rosendahl Dr Ben Cook Dr Greg Canning Interactive CD atlas of Dermoscopy A. Marghoob, R. Braun & A. Kopf 2006 Informa U.K. Ltd Further Reading Major texts/atlases Handbook of Dermoscopy [Mulvehy] Dermoscopy: The Essentials [Johr] An atlas of surface microscopy of pigmented skin lesions: Dermoscopy [Menzies] An atlas of dermoscopy [Marghoob] Websites
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