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Am Fam Physician. 2013;88(7):441-450

Related: Editor's Note

Related letter: Clarification Regarding AFP's Conflict of Interest Policy

Author disclosure: Dr. Marghoob reports receiving dermoscope prototypes for testing from the four major manufacturers of this device; receiving honoraria for speaking on the topic of dermoscopy; and participating in Institutional Review Board–approved research projects funded by the National Institutes of Health and Melanoma Research Alliance, some of which partnered with companies that produce dermoscopes. Drs. Usatine and Jaimes report no financial affiliations.

Dermoscopy has been shown to increase the clinician's diagnostic accuracy when evaluating cutaneous neoplasms. Two types of dermatoscopes are currently used: nonpolarized, which requires direct skin contact, and polarized, which does not require direct skin contact. A two-step algorithm for dermoscopic evaluation of skin lesions guides the clinician through the diagnosis and management decision-making process.

Noninvasive in vivo imaging techniques have become an important diagnostic aid for skin cancer detection. Dermoscopy, also known as dermatoscopy, epiluminescence microscopy, incident light microscopy, or skin surface microscopy, is performed using a handheld instrument called a dermatoscope or dermoscope, which has a transilluminating light source and standard magnifying optics (10×). The dermatoscope facilitates visualization of subsurface skin structures located within the epidermis, dermoepidermal junction, and papillary dermis, which are otherwise not visible to the unaided eye.1,2

Traditionally, dermoscopy has been taught to and used by dermatologists; however, it is gaining popularity in other fields of medicine, including primary care.35 Because many patients are seen routinely in the primary care setting, family physicians play an important role in screening for skin cancer and early detection of skin cancer. Dermoscopy has been shown to improve diagnostic accuracy, sensitivity, and specificity for skin cancer diagnosis by dermatologists.6 Once thought to be a subspecialist tool, the literature has shown that family physicians can also improve their diagnostic accuracy and triage ability by using dermoscopy.35,711

Clinical recommendationEvidence ratingReferences
Dermoscopy aids clinical examination in differentiating melanoma and basal cell carcinoma from benign skin lesions.C6, 17, 20
The first step in the two-step algorithm for dermoscopy is intended to help differentiate melanocytic lesions from nonmelanocytic lesions; however, its main objective is to prevent clinicians from missing melanomas.C36, 39
The second step in the two-step algorithm for dermoscopy is intended to help differentiate nevi from melanoma.C36


During naked eye examinations of the skin, much of the light transmitted toward the skin is reflected off the stratum corneum, thus precluding the observer from seeing structures located below this layer. Dermatoscopes illuminate the skin via the use of light-emitting diode bulbs, with or without the use of polarizing filters. Dermatoscopes using nonpolarized light require direct contact between the skin and the scope, and require a liquid interface, such as ultrasound gel or alcohol, to be placed between the skin and glass plate of the dermatoscope.12

Once the liquid interface has been applied to the skin, the scope can be placed on top of the lesion and gently pressed against the skin; it is imperative that enough pressure be applied to eliminate air bubbles. The liquid interface prevents light from being reflected off the stratum corneum and improves refraction, thereby allowing the visualization of structures below the stratum corneum. Dermatoscopes equipped with cross-polarized filters obviate the need for direct skin contact and a liquid interface.13 Cross-polarized filters eliminate the glare off the skin surface and increase light refraction, allowing the observer to visualize deeper skin structures.

Three types of dermoscopic techniques are currently used: (1) classic or standard contact; (2) polarized contact; and (3) polarized noncontact (Table 12,13 ). Studies have demonstrated that polarized and nonpolarized dermoscopy provide complementary information.14,15 Polarized dermoscopy may have a higher sensitivity for detecting skin cancer based on its ability to enhance the visualization of vascular and crystalline structures, both of which are commonly seen in skin cancer15,16 (Figure 1). Nonpolarized dermoscopy improves specificity because it permits easier visualization of other structures commonly seen in benign lesions, such as milia-like cysts in seborrheic keratosis.

Classic contact dermoscopyContact and noncontact dermoscopy
TechniqueRequires a liquid interface and direct contact between the scope and the skinAlthough it can be used in contact or noncontact mode, and can be used with or without a liquid interface, direct contact and liquid interface provide superior image clarity
Skin layersSuperficial layers are better visualizedDeep layers of epidermis and papillary dermis (depth of polarized light approximately 60 to 100 μm) are better visualized
Colors and structuresBlue-white veil due to orthokeratosis is more conspicuousPink and red colors are more conspicuous
Milia-like cysts and comedo-like openings are more conspicuousMilia-like cysts and comedo-like openings are less conspicuous
Steel blue color in blue nevi appears more homogeneousBlue color in blue nevi will appear darker, with differing hues
Regression structures (peppering, blue-white areas, and gray color) are more conspicuousWhite scar-like areas are more conspicuous
Ability to visualize vascular structures depends on the amount of pressure applied to the skinVascular structures and collagen are more conspicuous
White shiny structures cannot be visualized adequatelyWhite shiny streaks, also known as crystalline structures, are more conspicuous

Clinical Impact

Dermoscopy can enhance a clinician's ability to detect skin cancer. However, improvement in diagnostic accuracy is contingent on acquiring dermoscopy training. Without formal training, the use of dermoscopy may result in poorer performance compared with naked eye examination.17 Primary care physicians trained in dermoscopy can reduce their referral rate or benign-to-malignant excision ratio (from 9.5 to 3.5).5 In addition, primary care physicians trained in dermoscopy improve their ability to identify skin lesions suggestive of skin cancer compared with naked eye examination alone (76% to 79% vs. 54%).3,4 In other words, in primary care, dermoscopy improves sensitivity for the diagnosis of melanoma and improves the ability to recognize suspicious lesions that require biopsy, without significantly changing specificity (71%).35 Dermoscopy also has been shown to improve the diagnostic accuracy for nonmelanocytic lesions, such as basal cell carcinoma.18 The indications for dermoscopy are listed in Table 2,6,16,19,20 and the advantages and limitations are listed in Table 3.3,6,14,2032

Aid in the decision-making process as to whether to perform a biopsy; this is considered to be the most important function19
Evaluation of amelanotic lesions; this is feasible because of the ability to evaluate the morphology, distribution, and arrangement of blood vessels and white shiny structures16 (Figure 1)
Evaluation of pigmented and nonpigmented skin lesions; in particular, it helps differentiate melanoma and basal cell carcinoma from benign skin lesions6,20
Aids in diagnosis and differentiation of tumoral pathologies (i.e., basal cell carcinoma, dermatofibroma, seborrheic keratosis, hemangioma, melanoma, Spitz nevi, and clear cell acanthoma),14,21,22 and in the assessment of borders in some tumoral pathologies (e.g., lentigo maligna, basal cell carcinoma)23,24
Allows digital surveillance and monitoring of melanocytic lesions25,26
Allows clinician to formulate a more precise differential diagnosis (clinical-dermoscopy concordance)
Enhances confidence in the clinical diagnosis
Improves the diagnostic accuracy, sensitivity, and specificity for the diagnosis of melanoma6,20
Isolates suspicious areas within a lesion to help guide step-sectioning, which is performed by the pathologist
Reassures patients and physicians27
Reduces the number of unnecessary biopsies3,27,28
Anchoring bias (relying too heavily on one piece of information) and search satisfaction (basing a diagnosis on incomplete information and ending the search)
Can result in lower diagnostic accuracy if the physician does not recognize or correctly interpret the significance of structures29
May not detect early melanomas that have not yet developed any specific dermoscopic criteria30
Lower diagnostic accuracy when lesions are diagnosed using dermoscopy alone, without clinical context31,32

Essentials of Dermoscopy: Colors and Structures

The visualization of structures within the epidermis and papillary dermis using dermoscopy has generated new terminology and clinical criteria for cutaneous lesions.33 It is imperative that physicians using dermoscopy learn and become proficient at identifying the colors and structures, because they are required in generating a correct diagnosis.

Colors visible under dermoscopy depend on the quantity and location of keratin, blood, collagen, and melanin. Accordingly, colors visualized include yellow, red, and white for keratin, blood, and collagen, respectively. Colors for melanin range from black and brown to gray and blue, depending on the location of melanin, in terms of depth, within the skin layers.34

Structures visible under dermoscopy have histopathologic correlates (see Appendix below). The presence of specific structures permits the classification of a lesion as a melanocytic tumor (i.e., melanocytic nevus or melanoma). Common structures visualized in melanocytic lesions are provided in Table 421,22,3539 and Figure 2. When a lesion has been determined to be melanocytic, the next step is to determine if it is a nevus or a melanoma. Melanocytic nevi tend to manifest one of the symmetric patterns depicted in Figure 3, and melanomas reveal at least one of the 10 melanoma-specific structures provided in Table 5.

LevelType of lesionDermoscopic criteria
1Melanocytic lesionsPigment network*
Negative pigment network
Aggregated globules
Streaks (pseudopods and radial streaming)
Homogeneous blue pigmentation
Pseudonetwork (facial skin)
Parallel pigment pattern (acral lesions on palms and soles)
2Basal cell carcinoma35 Arborizing blood vessels
Leaf-like structures
Large blue-gray ovoid nests
Multiple blue-gray nonaggregated globules
Spoke wheel–like structures/concentric structures
3Seborrheic keratosis36,37 Multiple (thee or more) milia-like cysts
Comedo-like opening
Moth-eaten borders
Gyri (ridges) and sulci (fissures)
Fingerprint-like structures
4Hemangioma/angiokeratoma36 Red, maroon, or black lacunae
5Blood vessels seen in nonmelanocytic tumors22,36 Arborizing, glomerular, hairpin, crown, and serpiginous vessels
6Blood vessels seen in melanocytic tumors21,36 Comma-shaped, dotted, serpentine or irregular linear, polymorphous, and corkscrew vessels; milky-red globules/vascular blush
7Structureless lesions36 No structures or blood vessels noted
Melanoma-specific structureDefinitionSchematic illustration
Irregular or atypical pigment networkNetwork with increased variability in the thickness and color of the lines of the network, and increased variability in the size and shape of the holes
Negative pigment networkSerpiginous interconnecting hypopigmented lines that surround irregularly shaped pigmented structures resembling elongated curvilinear globules
Streaks (pseudopods and radial streaming)Radial projections at the periphery of the lesion that are focally and asymmetrically distributed
Off-centered blotchAsymmetrically or focally located at the periphery of the lesion
Irregular blotch will often reveal differing hues
Atypical dots or globulesMultiple dots or globules of different size, shape, and color
Asymmetrically or focally distributed within the lesion
Regression structuresInclude scar-like depigmentation and peppering, which, when combined, give the appearance of a blue-white veil
Blue-white veil overlying raised areasTends to be asymmetrically located or diffuse throughout the lesion with differing hues
Atypical vascular structuresDotted vessels over milky-red backgrounds
Serpentine (irregular linear) vessels
Polymorphous vessels
Crystalline structuresWhite shiny streaks or lines organized orthogonally
Peripheral brown structureless areasTan areas located at the periphery of the lesion that encompass greater than 10% of the lesion

Nonmelanocytic lesions, including basal cell carcinoma, seborrheic keratosis, hemangioma, and angiokeratoma, also demonstrate specific structures under dermoscopy. Pigmented and nonpigmented basal cell carcinomas can reveal vascular structures such as arborizing blood vessels36,38 (Table 421,22,3539 ; Figure 4). In addition, pigmented basal cell carcinoma can demonstrate pigmented structures, including leaf-like structures, spoke wheel–like structures, ovoid nests, and nonaggregated blue-gray globules.

Seborrheic keratosis is one of the most common benign epidermal tumors. Clinically, these lesions are characterized by well-circumscribed plaques or papules with pseudohorn cysts. They range from light brown to dark brown or black. Dermoscopically, seborrheic keratoses display multiple milia-like cysts, comedo-like openings, gyri and sulci, fingerprint-like structures, and moth-eaten borders (Table 421,22,3539; Figure 5).

Cherry hemangiomas are bright red to violaceous papules that consist of dilated capillaries. Similarly, angiokeratomas are dark violaceous to black papules that are often keratotic or firm on palpation. Dermoscopically, hemangiomas and angiokeratomas are distinguished by the presence of well-demarcated lacunae that can be red, maroon, blue, or black 36 (Table 421,22,3539; Figure 6).

Some lesions, particularly amelanotic or hypomelanotic tumors, cannot be classified based on the aforementioned features. It is important to search for the presence of blood vessels in these lesions. If present, the blood vessel morphology can assist in making the correct diagnosis. In most amelanotic and hypomelanotic lesions, the only clue to the diagnosis depends on evaluating the blood vessel morphology and distribution, whereas in pigmented lesions (as previously mentioned), the analysis of vascular structures provides secondary clues to the diagnosis.21,40

The easiest way to visualize blood vessels is to use a noncontact polarized dermatoscope. If a contact dermatoscope is used, it is beneficial to use ultrasound gel as the liquid interface, because the gel acts as a cushion that minimizes the amount of pressure applied to the skin, which in turn prevents blanching of the vessels.21 Although it is important to analyze blood vessel morphology, especially in amelanotic lesions, it is beyond the scope of this article to review all the vessel morphologies; readers should refer to the referenced articles for more information.21,22

Interpretation of Dermoscopic Structures: The Two-Step Algorithm

The two-step dermoscopy algorithm is the foundation for dermoscopic evaluation of skin lesions, and it guides the observer through the diagnosis and management decision-making process36 (Figure 7).


The first step of the algorithm is based on a seven-level criterion ladder, which is intended to help differentiate melanocytic lesions from the following nonmelanocytic lesions: dermatofibroma, basal cell carcinoma, seborrheic keratosis, and hemangioma36 (Table 421,22,3539 ; Figure 7). Even if the two-step algorithm cannot reliably differentiate between melanocytic and nonmelanocytic lesions, it has been structured to ensure that cutaneous malignancies will not be missed.36,39 For example, occasionally basal cell carcinoma and melanoma can manifest overlapping features that may lead to the incorrect classification of some basal cell carcinomas as melanocytic (i.e., melanoma) and some melanomas as nonmelanocytic (i.e., basal cell carcinoma). Despite this potential error, the concern for a cutaneous malignancy will remain high, and the management decision to perform a biopsy will not be altered.


The second step of the algorithm is intended only for the evaluation of melanocytic lesions, including common acquired melanocytic nevi, blue nevi, Spitz nevi, atypical nevi, and melanoma. In essence, the second step is intended to help differentiate nevi from melanoma.36 To accomplish this, numerous quantitative and qualitative methods have been created.34,4145 In particular, scoring systems have proven to be relatively simple, accurate, and reproducible methods for diagnosing melanoma.6,19,44

The three-point checklist is considered the simplest method to learn and use, and has the highest sensitivity for identifying melanoma36 (Figure 8). It is intended as a screening algorithm for detecting skin cancer (melanoma and pigmented basal cell carcinoma) and applies only to pigmented skin lesions. One point is assigned to each of the following criteria present in the lesion43:

  • Asymmetry in distribution of dermoscopic color and/or structures in one or two perpendicular axes. The contour or silhouette of the lesion does not factor into whether the lesion is symmetric or not.

  • Irregular or atypical pigment network consisting of thick lines and irregular holes.

  • Blue-white veil and/or white scar-like depigmentation and/or blue pepper-like granules.

A total score of 2 or 3 is considered positive, and the lesion should be biopsied or the patient referred for further evaluation.43 Given its simplicity and high sensitivity for detecting pigmented skin cancer, the three-point checklist may be ideally suited for clinicians with little experience in dermoscopy and for use as a screening tool in the primary care setting.19 Atypical pigment network and blue-white structures have previously been defined (Figure 2; Table 5; Appendix). Dermoscopic asymmetry requires further clarification, because it differs from the conventional way that clinicians define asymmetry. The conventional view of asymmetry, as in the well-known ABCD mnemonic for melanoma (asymmetry, border irregularities, color variation, diameter [greater than 6 mm]), factors in the contour or shape of the lesion. In contrast, symmetry or asymmetry in dermoscopy does not factor in the contour or shape, but rather the distribution of colors and structures within the lesion (Figure 8). For example, using the conventional definition of symmetry, a heart-shaped lesion that reveals only globules would be considered asymmetric in one axis; however, under dermoscopy, this lesion would be considered completely symmetric in both axes.

Pattern analysis is a qualitative method that evaluates dermoscopic structures and their distribution. It requires the ability to recognize, and experience in recognizing, benign patterns4648 (Figure 3). It also requires the ability to recognize the 10 melanoma-specific structures listed in Table 5. Any melanocytic lesion that deviates from one of these benign patterns, while also revealing at least one of the 10 melanoma-specific structures, should be biopsied to rule out melanoma.

Dermoscopy as a Guide for Management

From a management perspective, the two-step algorithm (Figure 7) is intended to guide the decision-making process on whether to perform a biopsy, or to refer or reassure the patient.49

If the lesion is considered benign, the patient can be reassured, provided education on skin self-examination, and instructed to return if any changes or new lesions develop.25,50 If the lesion is suspicious for melanoma or basal cell carcinoma, it should be biopsied.51 If the lesion is considered suspicious (i.e., the clinician is uncertain of the diagnosis), it can be biopsied or the patient can be referred for another opinion.

All of the criteria discussed in this article can be applied during the evaluation of any lesion on any area of the skin. However, there are additional criteria that are specific to mucosal, volar, and facial skin lesions. For discussion of the specific features of lesions on these areas, refer to the Atlas of Dermoscopy52 or other online tutorials on dermoscopy, such as and

Dermoscopy is a useful, easy-to-use, and non–time-consuming technique that increases diagnostic accuracy for pigmented and nonpigmented skin lesions53; in particular, it increases the sensitivity for detecting melanoma and basal cell carcinoma. In addition, dermoscopy has been shown to improve specificity by decreasing the number of biopsies of benign lesions, such as nevi, seborrheic keratosis, and hemangioma, that may clinically mimic malignancy.28

Data Sources: A PubMed search was completed in Clinical Queries using the key terms dermoscopy, dermatoscopy, epiluminescence microscopy, skin surface microscopy, and incident light microscopy. The search included meta-analyses, randomized controlled trials, clinical trials, reviews, and case series.

EDITOR'S NOTE: At the time of initial submission, Dr. Marghoob did not list any disclosures on AFP's Conflict of Interest form, which asks for financial relationships with commercial entities that might have an interest in the topic. During the final stages of production, we discovered that Dr. Marghoob had the following relationships with makers of dermoscopes, which we agreed should be disclosed: (1) receiving dermoscope prototypes for testing from the four major manufacturers, and providing unpaid feedback and advice about these devices; (2) receiving honoraria for speaking on the topic of dermoscopy at meetings funded in part by makers of dermoscopes (however, Dr. Marghoob is not on any speakers' bureaus); and (3) being an investigator in Institutional Review Board–approved research projects funded by the National Institutes of Health and Melanoma Research Alliance, some of which partnered (at least to some extent) with companies that produce dermoscopes (however, Dr. Marghoob does not receive any compensation from this grant funding). Given the stage at which these conflicts came to our attention, we performed an internal review of the manuscript and disclosures, and ultimately decided that the manuscript provided an unbiased and nonpromotional description of this technique. In addition, Dr. Marghoob agreed to not enter into any relationships with a maker of dermoscopes that used his AFP article for any presentations on dermoscopy for at least 12 months after the article's publication. For these reasons, we decided to continue with publication. However, to be clear, relationships like these would generally be disqualifying according to our conflict of interest policy (


Dermoscopic structuresSchematic illustrationDefinitionHistopathologic correlation
Pigment networkGrid-like network consisting of pigmented lines and hypopigmented holesMelanin in keratinocytes or melanocytes along the dermoepidermal junction
Network lines correspond to the rete ridges
Holes correspond to the suprapapillary plate
PseudonetworkDiffuse pigmentation interrupted by adnexal openingPigment in the epidermis or dermis in which the rete ridges are attenuated
Usually seen in facial lesions
Negative pigment networkSerpiginous interconnecting hypopigmented lines that surround irregularly shaped pigmented structures resembling elongated curvilinear globulesRemains unknown
Presumed to be related to bridging of rete ridges or large melanocytic nests in the papillary dermis, resulting in compression of adjacent rete ridges; these nests may correspond to globules that are not spherical in shape
Aggregated globulesMore than three clustered, well- demarcated, round to oval, symmetric structures, or three or more of these structures aligned at the lesion's perimeterNests of melanocytes at the dermoepidermal junction
May be brown, black, or blue
Diameters are greater than 0.1 mm
DotsSmall, round structures of less than 0.1 mm in diameterAggregates of melanocytes or melanin granules
May be black, brown, or blue-gray
Streaks (pseudopods and radial streaming)Streaks are radial projections at the periphery of the lesion, extending from the tumor toward the surrounding normal skin; may be brown or blackConfluent junctional nests of melanocytes
Pseudopods are streaks with finger-like projections with small knobs at the tips
Radial streaming is streaks without knobs at the tips
Peppering (or granularity)Tiny, blue-gray granulesMelanin deposited as intracellular (mostly within melanophages) or extracellular particles in the upper dermis
Structureless areasDevoid of dermoscopic structures within the lesion and without manife sting any regression structuresRelative decreased concentration of melanin or flattening of rete ridges
Tend to be tan to light brown, but have lighter pigment compared with the rest of the lesion
Peripheral light brown or tan structureless areasStructureless areas (as above), located at the periphery of the lesionPartial or complete flattening of the rete ridges
Increased number of pigmented atypical melanocytes predominantly at the dermoepidermal junction
Diffuse scattering of melanocytes in the spinous layer of the epidermis
Regression structures Dark brown to black homogeneous areas of pigment that obscure visualization of any other structuresAggregates of melanin in the stratum corneum or throughout all layers of the skin
BlotchesInclude scar-like depigmentation (lighter than the surrounding uninvolved normal skin; appear shiny white under polarized dermoscopy) often combined with peppering; combination of scar-like depigmentation and peppering gives the appearance of a blue-white veilScar-like changes/white areas: thickened fibrotic papillary dermis Blue areas: correlate with melanosis type of regression
Blue-white veilConfluent blue pigmentation with an overlying white ground-glass hazeAggregation of heavily pigmented melanocytes or melanophages in combination with compact orthokeratosis of the stratum corneum
White shiny structures (more conspicuous with polarized dermoscopy)Rosettes: appear as four white shiny points creating a pattern reminiscent of a four- leaf cloverA4 Histopathologic correlation has not been fully explained
Crystalline structures: short, white, shiny linear streaks that are often parallel or orthogonal to each otherA5, A6 Altered collagen or fibrosis in the dermis
White shiny areas: appear as larger structureless areas of shiny white colorAltered stromal matrix
Parallel pigment patternOn volar skin (i.e., palms and soles)Pigmented melanocytes in the furrows (crista limitants) or ridges (crista intermedia) on skin of palms and soles
Parallel rows of pigmentation following the furrows (as seen in nevi) or ridges (as seen in melanoma) of the dermatoglyphics
Dermoscopic structuresSchematic illustrationDefinitionHistopathologic correlation
Milia-like cystsRound whitish or yellowish structures that shine brightly (like “stars in the sky”) under nonpolarized dermoscopyIntraepidermal keratin-filled cysts
Further subclassified as small and starry, and as large and cloudy A9
Comedo-like openingsBlackhead-like plugs on the surface of the lesionConcave invaginations in the surface of the epidermis filled with keratin; some of these invaginations may correspond to follicular openings filled with keratin
Fingerprint-like structuresDelicate, thin, light brown parallel running lines that do not interconnect to form a gridEpidermal ridges
Gyri and sulciGyri (ridges or fat fingers) and sulci (fissures) that create a cerebriform surfaceEpidermal ridges with or without keratin filling the invaginations
These invaginations can be filled with keratin, creating crypts
Moth-eaten bordersConcave invaginations of the lesion border
Pigment network–like structureGrid-like pattern that can resemble the pigment network seen in a melanocytic neoplasmRidges, crypts, and comedo-like openings distributed in a manner that gives the appearance of a grid
Correspond to interconnecting epidermal ridges on the skin; the holes correspond to comedones or crypts
Lines tend to appear broader compared with the pigment network seen in nevi
Leaf-like structuresBrown to gray-blue discrete bulbous structures that may coalesce to create a shape that resembles a leafLarge pigmented basal cell carcinoma tumor nests in the upper dermis
Spoke wheel–like/concentric structuresWell-circumscribed brown to gray-blue-brown radial projections meeting at a darker brown central hubBasal cell carcinoma tumor nests radiating from the dermoepidermal junction
Large blue-gray ovoid nestsLarge, well-circumscribed ovoid areas; larger than globulesLarge basal cell carcinoma tumor nests in the dermis
Blue-gray globules or dotsMultiple, nonaggregated, round, well-circumscribed structuresSmall basal cell carcinoma tumor nests in the dermis
LacunaeRed (hemangioma), maroon (hemangioma and angiokeratoma), or black (angiokeratoma) lagoons often separated by septaeDilated vascular spaces
Dermoscopic structuresSchematic illustrationDefinition (morphology)Diagnostic associations
Glomerular vesselsCoiled vessels mimicking the glomerular apparatus of the kidneyBowenoid actinic keratosis, Bowen disease/squamous cell carcinomaA11,A13
Clear cell acanthoma
Hairpin vesselsU-shaped vesselsKeratinizing tumors such as keratoacanthoma and seborrheic keratosisA7,A11,A14
Not infrequently, may be twisted on its axis
Background: white halo common in keratinocytic tumors
U-shaped vesselsIrritated seborrheic keratosis, melanoma, basal cell carcinomaA15
Not infrequently, may be twisted on its axis
Background: pink halo or pink background common in irritated seborrheic keratosis, but can also be seen in cutaneous malignancies
Arborizing vesselsVessels with large diameter, branching irregularly into fine capillariesBasal cell carcinomaA11, A13
Can also be seen in cysts, furuncles, and other adnexal tumors
Crown vesselsBranching or nonbranching vessels radiating toward the center of the lesion but without crossing its centerSebaceous hyperplasiaA11
Molluscum contagiosum
Often associated with white/yellowish popcorn-like globular structures
Dotted or glomerular vessels in “string of pearls” or serpiginous distributionVessels distributed in a serpiginous patternClear cell acanthoma
Strawberry patternWhite-yellow follicular openings surrounded by a white halo, over a red backgroundActinic keratosisA16
Dermoscopic structuresSchematic illustrationDefinition (morphology)Diagnostic associations
Comma-shaped vesselsSlightly curved vesselsDermal nevi, congenital melanocytic neviA11
Dotted vesselsRed dots (0.01 to 0.02 mm)Spitz nevi, early melanoma (dotted over milky-red background)A11
Clark nevi (dotted over tan background)
Serpentine vesselsIrregular linear/undulating short vesselsMelanoma, congenital neviA11
Milky-red globules/vascular blushIll-defined globules of milky-red color and ill-defined areas of milky-red colorAmelanotic melanomaA11
Polymorphous vesselsCombination of two or more vessel morphologiesMelanomaA14
Most common combination is dotted and serpentine vessels
Corkscrew vesselsCoiled and tortuous vesselsCutaneous melanoma metastases, nodular melanoma, desmoplastic melanoma

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