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Figure 1.Consensus process using a 2-phase modified Delphi method.
Tables
- Table 1.
Demographic Characteristics of Larger Expert Panel (n = 35 Participants in First Round)
Specialty (n = 35) Count % Family medicine 19 54.3% Internal medicine 2 5.7% Medicine—pediatrics 0 0.0% Dermatology 14 40.0% Other 0 0.0% Dermoscopy use in clinical practice (n = 35) Count % Yes 35 100% No 0 0.0% No. years of dermoscopy use in clinical practice (n = 35) Count % 0 to 1 year 0 0.0% 1 to 5 years 16 45.7% 6 to 10 years 10 28.6% 11 to 15 years 4 11.4% 15 + years 5 14.3% Specialization in pigmented lesions, dermoscopy, or melanoma as an attending physician (n = 35) Count % Yes 16 45.7% No 19 54.3% No. years of specialization in pigmented lesions, dermoscopy, or melanoma as an attending physician (n = 16) Count % 0 to 1 year 0 0.0% 1 to 5 years 7 43.8% 6 to 10 years 2 12.5% 11 to 15 years 4 25.0% 15 + years 3 18.8% Direct involvement in dermoscopy training for primary care (n = 35) Count % Yes 22 62.9% No 13 37.1% If directly involved in dermoscopy training for primary care, type of training offered* (n = 22) Count % Dermoscopy training in clinic 18 81.8% Dermoscopy training in a lecture format 15 68.2% Other† 3 13.6% Category Level 1 (Foundational) Level 2 (Intermediate) Neither Nonmelanocytic lesions Hemangioma
Sebaceous hyperplasia
Clear cell acanthoma
Seborrheic keratosis
Pigmented actinic keratosis
Merkel cell carcinoma†
Dermatofibroma
Squamous cell carcinoma in situ
Porokeratosois†
Solar lentigo
Keratoacanthoma
Poroma‡
Basal cell carcinoma
Angiokeratoma
Xanthogranuloma‡
Squamous cell carcinoma
Lichen planus-like keratosis
Actinic keratosis
Ink spot lentigo†
Benign melanocytic lesions Overview of benign nevi patterns
Blue nevi
Combined nevi†
Intradermal nevi
Spitz nevi
Congenital melanocytic nevi
Recurrent/persistent nevi
Halo nevi†
Melanoma Overview of melanoma patterns
Acral melanoma
Desmoplastic melanoma†
Lentigo maligna melanoma
Nevoid melanoma†
Melanoma of the nail
Verrucous melanoma†
Amelanotic/hypomelanotic melanoma
Special sites Subungual hemorrhage Dermoscopic features of the face
Nevi of the mucosa†
Benign patterns of acral nevi
Nevi of the mucocutaneous junction†
Nevus of the nail
Lentigo of the nail
Talon noir†
Other Verruca*
Molluscum contagiosum*
Atopic dermatitis†
Scabies
Radiation tattoo*
Scars*
Venous lake*
Psoriasis†
↵* Suggested by the expert focus group to add onto the Melanoma Prevention Working Group-Pigmented Lesions Subcommittee consensus-based list for dermatology residents.
↵† Suggested by a panelist during round 1 of the diagnoses survey series.
↵‡ Suggested by a panelist during round 2 of the diagnoses survey series.
Diagnosis (Level 1 or 2)
Feature included as a learning objective (>70% positive responses)Round 1: % Positive Responses* (n = 33) Round 2: % Positive Responses* (n = 30) Hemangioma (level 1) Red, blue-red, red-purple, or maroon lacunae/lagoons with white septae 72.7% — Blue-black coloring in lacunae (when thrombosed) in absence of other structures 72.7% — Seborrheic keratosis (level 1) Milia-like cysts (cloudy or starry) and comedo-like openings 93.9% — “Fissures and ridges”/“gyri and sulci”/cerebriform pattern 93.9% — Moth-eaten (sharply demarcated) borders 87.9% — Fat fingers 78.8% — Fingerprint-like structures (parallel lines) 78.8% — Hairpin (looped) vessels 78.8% — Dermatofibroma (level 1) Central scar-like white patch/depigmentation 100.0% — Fine/delicate surrounding/peripheral network-like structures 100.0% — Central shiny white lines/streaks under polarized dermoscopy 84.8% — Ring-like globules 66.7% ↓ 60.0% Solar lentigo (level 1) Moth-eaten (sharply demarcated) borders 90.9% — Fingerprint-like structures (parallel lines) 90.9% — Homogenous light brown pigmentation 87.9% — Uniform brown perifollicular pigmentation 75.8% — Network-like structures 63.6% ↓ 63.3% Basal cell carcinoma (level 1) Arborizing vessels 97.0% — Ulceration/erosion 93.9% — Leaf-like structures/areas 90.9% — Blue-gray ovoid nests 87.9% — Spoke-wheel-like structures/areas/concentric structures 87.9% — Multiple blue-gray dots and globules (buckshot scatter) 84.8% — Shiny white blotches and strands/structures under polarized dermoscopy 69.7% ↑ 76.7% Short fine telangiectasias (superficial BCC) 69.7% ↑ 70.0% Squamous cell carcinoma (level 1) Yellow keratin mass/scale-crust 100.0% — Ulceration/blood spots/hemorrhage 93.9% — White circles (“keratin pearls”) 90.9% — Glomerular (coiled) vessels 90.9% — Hairpin vessels 78.8% — Rosettes 75.8% — Actinic keratosis (level 1) Surface scale 97.0% — Rosettes 81.8% — Strawberry pattern (pink-red pseudonetwork ± fine wavy vessels [straight or coiled] surrounding hair follicles ± white circles with central yellow clod [targetoid hair follicles]) 78.8% — Sebaceous hyperplasia (level 2) Pale yellow lobules (popcorn-like structures) around a central follicular opening 100.0% — Crown vessels, out of focus 90.9% — Pigmented actinic keratosis (level 2) Surface scale 90.9% — Rosettes 75.8% — Annular-granular pattern (gray dots around follicular openings) 66.7% ↓ 53.3% Red pseudonetwork† 57.6% — Patent/evident follicles† 57.6% — Squamous cell carcinoma in situ (level 2) Irregularly arranged glomerular (coiled)/dotted vessels 93.9% — Surface scale 87.9% — Keratoacanthoma (level 2) Central keratin mass 93.9% — Hairpin (looped) or serpentine (linear-irregular) vessels, usually at the periphery, with white-yellow halo 87.9% — Angiokeratoma (level 2) Red/purple/black (“dark”) lacunae 93.9% — Hemorrhagic crust 75.8% — Lichen planus-like keratosis (level 2) Features of a lentigo or seborrheic keratosis in an area 72.7% — Peppering (evenly spaced gray dots) 69.7% ↓ 63.3% Sharp cut-off borders (scalloped/moth-eaten) 69.7% ↓ 63.3% Coarse gray granularity 63.6% ↓ 53.3% Ink spot lentigo (level 2) Prominent dark homogenous (uniform) reticular network 93.9% — Chicken-wire fence 63.6% ↓ 50.0% ↵* % of panelists who indicated on a 5-point Likert scale that they “strongly agree” (5) or “agree” (4) with the feature being included in dermoscopy training for primary care providers.
↵† Suggested by a panelist during round 1 of the features survey series.
Abbreviations: BCC, basal cell carcinoma; SCCIS, squamous cell carcinoma in situ (Bowen’s disease).
Diagnosis (Level 1 or 2)
Feature included as a learning objective (>70% positive responses)Round 1: % Positive Responses* (n = 33) Round 2: % Positive Responses* (n = 30) Overview of benign nevi patterns (level 1) Diffuse reticular network 100.0% — Peripheral reticular network with central hypopigmentation 100.0% — Peripheral reticular network with central hyperpigmentation 100.0% — Globular pattern 100.0% — Patchy reticular network 97.0% — Homogenous (tan, brown, blue, or pink) 93.9% — Peripheral reticular network with central globules 90.9% — Central network with evenly distributed peripheral globules 87.9% — Symmetric multicomponent pattern 75.8% — Symmetric two-component pattern 69.7% ↓ 60.0% Intradermal nevi (level 1) Comma-shaped (curved) vessels 93.9% — Homogenous (structureless) brown/tan/pink pigmentation 93.9% — Peripheral network 72.7% — Globules 87.9% — Blue nevi (level 2) Homogenous blue/blue-gray pigmentation 100.0% — Well-circumscribed lesion 93.9% — Spitz nevi (level 2) Starburst pattern with tiered globules/streaks and regularly spaced pseudopods at the periphery (radial streaming) 87.9% — Vascular pattern (pink homogenous with dotted vessels) 75.8% — Congenital melanocytic nevi (level 2) Cobblestone pattern/globular pattern 93.9% — Reticular network 90.9% — Homogenous background pigmentation 87.9% — Hypertrichosis 78.8% — Perifollicular hyper-/hypopigmentation 69.7% ↓ 60.0% Recurrent/persistent nevi (level 2) Pigment within the scar, not extending beyond 81.8% — Halo nevi (level 2) Encircling/surrounding depigmentation/pallor 93.9% — Central reticulation with peripheral white depigmentation 78.8% — Benign nevi patterns, globular, homogenous 78.8% — ↵* % of panelists who indicated on a 5-point Likert scale that they “strongly agree” (5) or “agree” (4) with the feature being included in dermoscopy training for primary care providers.
Diagnosis (Level 1 or 2)
Feature included as a learning objective (>70% positive responses)Round 1: % Positive Responses* (n = 33) Round 2: % Positive Responses* (n = 30) Overview of melanoma patterns (level 1) Blue structures (blue-white veil, blue-gray structures) 100.0% — Shiny white lines/structures (crystalline structures) 100.0% — Atypical pigment network 97.0% — Atypical/irregular streaks (radial streaming, pseudopods) 97.0% — Atypical/irregular dots/globules 93.9% — Regression structures (white scar-like area and/or peppering) 93.9% — Negative pigment network 87.9% — Atypical vascular pattern/structures, polymorphous vessels (2 + types of blood vessels) 87.9% — Peripheral brown/tan structureless area 78.8% — Angulated lines (extrafacial)/polygons/zig-zag pattern 75.8% — Atypical/off-center blotch(es) 69.7% ↑ 90.0% Acral melanoma (level 2) Parallel ridge pattern 93.9% — Ulceration 90.9% — Irregular diffuse pigmentation or blotch 84.8% — Multicomponent pattern, asymmetry of structures/colors 84.8% — Atypical fibrillar pattern 72.7% — Neovascularization, milky red 72.7% — Lentigo maligna melanoma (level 2) Annular-granular pattern (gray dots around follicular openings) 90.9% — Asymmetric pigmentation around follicular openings/asymmetric follicular openings 87.9% — Rhomboidal structures (angulated lines)/zig-zag pattern 81.8% — Dark blotches ± obliterated hair follicles 75.8% — Circle within a circle (isobar) 60.6% ↓ 56.7% Melanoma of the nail (level 2) Pigmentation of periungual skin (micro-Hutchinson's sign) 90.9% — Triangular shape of pigment band (band diameter wider at proximal end) 87.9% — Longitudinal brown/black broken lines with irregular spacing, width, coloration, or parallelism 81.8% — Band width >3 mm or two thirds of nail plate width 78.8% — Brown to black dots/globules associated with longitudinal lines 60.6% ↓ 50.0% Amelanotic/hypomelanotic melanoma (level 2) Milky red areas 81.8% — Shiny white lines (crystalline structures) 81.8% — Atypical vascular pattern, polymorphous vessels (2 + types of blood vessels) 81.8% — Scar-like depigmentation 75.8% — ↵* % of panelists who indicated on a 5-point Likert scale that they “strongly agree” (5) or “agree” (4) with the feature being included in dermoscopy training for primary care providers.
Diagnosis (Level 1 or 2)
Feature included as a learning objective (>70% positive responses)Round 1: % Positive Responses* (n = 33) Round 2: % Positive Responses* (n = 30) Subungual hemorrhage (level 1) Well-circumscribed red-black dots or blotches/blood spots 90.9% — Discontiguous with the cuticle (not connected to the proximal nailfold or edge of nail) 87.9% — Distal streaks of red-brown coloration (“filamentous” distal end) 81.8% — Homogenous red/purple/black coloration without melanin granules 69.7% ↓ 60.0% Dermoscopic features of the face (level 2) Pseudonetwork 78.8% — Benign patterns of acral nevi (level 2) Parallel furrow pattern (with pattern variations including single line, double line, single dotted line, double dotted line) 93.9% — Lattice-like pattern 87.9% — Fibrillar pattern (soles only) 84.8% — Homogenous pattern 75.8% — Peas-in-a-pod pattern (parallel furrow + globules on ridges) (acral congenital melanocytic nevi) 69.7% ↓ 56.7% Nevus of the nail (level 2) Uniform band thickness, color, and spacing with parallel band configuration and unbroken lines 87.9% — Homogenous brown background coloration 84.8% — Lentigo of the nail (level 2) Homogenous gray band or lines ± gray background 78.8% — Regular light-brown lines† — 60.0% Talon noir (level 2) Homogenous red-brown coloration 78.8% — Cracks (lightning bolt sign)‡ 51.5% — ↵* % of panelists who indicated on a 5-point Likert scale that they “strongly agree” (5) or “agree” (4) with the feature being included in dermoscopy training for primary care providers.
↵† Suggested by a panelist during round 1 of the dermoscopic features survey series.
‡ Feature did not undergo a revote in round 2 due to original threshold criteria for a revote being <70% but >60% positive responses.
- Table 7.
Dermoscopic Characteristics of Other Diagnoses, Including Skin Infections and Infestations
Diagnosis (Level 1 or 2)
Feature included as a learning objective (>70% positive responses)Round 1: % Positive Responses* (n = 33) Round 2: % Positive Responses* (n = 30) Verruca (level 1) Papilliform structures 93.9% — Tiny red-black dots (papillary capillaries) 90.9% — Scabies (level 1) Delta-wing jet with contrail sign (small dark brown triangular structure located at the end of whitish structureless curved/wavy lines) 90.9% — Molluscum contagiosum (level 2) Central pore or umbilication 93.9% — Polylobular white-yellow amorphous structures 81.8% — Linear or branched vessels (red corona)/crown vessels 63.6% ↓ 63.3% Radiation tattoo (level 2) Homogenous blue or black coloration 84.8% — Scars (level 2) White depigmentation 72.7% — Venous lake (level 2) Homogenous purple/blue/red coloration ± globules/clods 93.9% — Psoriasis (level 2) Red or pink color with white scales/light-red background 75.8% — Dotted vessels in a regular distribution 72.7% — ↵* % of panelists who indicated on a 5-point Likert scale that they “strongly agree” (5) or “agree” (4) with the feature being included in dermoscopy training for primary care providers.
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