Impact of Dermoscopy on the Clinical Management of Pigmented Skin Lesions GIUSEPPE ARGENZIANO, MD H. PETER SOYER, MD SERGIO CHIMENTI, MD GABRIELE ARGENZIANO, MD VINCENZO RUOCCO, MD I n the last two decades, a rising incidence of mela- noma has been observed. Owing to the lack of adequate therapies for metastatic melanoma, the best treatment currently is still early diagnosis and prompt surgical excision of the primary tumor. In the 1960s and 1970s, the clinical diagnosis of mel- anoma was based on symptoms—namely, bleeding, itching, and ulceration—and the presence of all of the symptoms is associated with poor prognosis at the time of diagnosis. In the 1980s the ABCD rule was intro- duced, which is based on simple, clinical, morphologic features of melanoma (asymmetry, border irregularity, color variegation, and diameter 5 mm). 1 Since then, the ABCD rule has been used worldwide, allowing early detection of a high number of melanomas. Further improvement might be achieved by adding to the ABCD rule a fifth criterion, called E for evolution, con- cerning morphologic changes of the lesion over time. 2 There are, however, two major problems with the current practice of clinical diagnosis of melanoma. First, clinical diagnosis based on the ABCD rule reaches only 65%– 80% sensitivity 3,4 because this method does not recognize that small melanomas (5 mm) may occur. In addition, very early melanomas may have a regular shape and homogeneous color; such lesions would falsely be assessed as benign. Second, numerous unnec- essary excisions may be performed, since a number of benign melanocytic nevi may mimic melanoma from a clinical point of view. It has been reported that in Australia, the ratio of melanoma to benign pigmented skin tumors removed by dermatologists and general practitioners is 1:12 and 1:30, respectively. 5 The introduction of dermoscopy into the clinical practice of dermatology has disclosed a new and fasci- nating morphologic dimension of pigmented skin le- sions (PSLs). Dermoscopy is a noninvasive, simple, and inexpensive diagnostic technique that permits the visu- alization of morphologic features that are not visible to the naked eye, thus forming a link between macro- scopic clinical dermatology and microscopic dermato- pathology. This “submacroscopic” observation of PSLs enriches the available clinical diagnostic tools by pro- viding new morphologic criteria for the differentiation of melanoma from other melanocytic and nonmelano- cytic PSLs. 6,7 Over the past years, dermoscopy has been known by a variety of names, including skin surface microscopy, epiluminescence microscopy, incident- light microscopy, dermatoscopy, and videodermato- scopy. The term “dermoscopy,” however, first used by Friedman et al 8 in 1991, currently enjoys the greatest international consensus. Dermoscopy involves covering the skin lesion with mineral oil, alcohol, or even water and then inspecting the lesion with a hand-held lens, a hand-held scope (also called a dermatoscope), a stereomicroscope, a camera, or a digital imaging system. Magnifications of these various instruments range from 6 to 40 and even up to 100. The widely used dermatoscope has a 10-fold magnification, sufficient for routine assessment of PSLs. The fluid placed on the lesion eliminates sur- face reflection and renders the cornified layer translu- cent, thus allowing better visualization of pigmented structures within the epidermis, the dermal-epidermal junction, and the superficial dermis. Moreover, size and shape of vessels of the superficial vascular plexus can be easily visualized by this procedure. New hand-held dermatoscopes are now available on the market, which are provided with polarized light, rendering the fluid placed on the lesion unnecessary for inspecting pig- mented skin structures. It has been claimed that dermoscopy improves the sensitivity (up to 35%) and specificity of melanoma From the Department of Dermatology, Second University of Naples, Naples, Italy; the Department of Dermatology, University of Graz, Graz, Austria; and the Department of Dermatology, University Tor Vergata of Rome, Rome, Italy. Address correspondence to Giuseppe Argenziano, MD, Department of Dermatology, Second University of Naples, Via Pansini 5– 80131 Naples, Italy. E-mail address: argenziano@tin.it © 2002 by Elsevier Science Inc. All rights reserved. 0738-081X/02/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0738-081X(02)00234-1