10.5826/dpc.1304S1a305S
text/xml
2160-9381
3622
en
Giuseppe Argenziano
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
systematic review
Dermoscopy in Skin of Color: The Journey So Far
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Editorial
2023-10-04
2023-06-19
2023-10-04
2023-11-27
e2023305S
Dermatol Pract Concept
Giuseppe Argenziano
2023/10/04
10.5826/dpc.1304S1a305S
e2023305S
Unit of Dermatology, Luigi Vanvitelli University of Campania, Naples, Italy
2160-9381
systematic review
en
e2023305S
Ankad BS, Behera B, Lallas A, et al. International Dermoscopy Society (IDS) Criteria for Skin Tumors: Validation for Skin of Color Through a Delphi Expert Consensus by the "Imaging in Skin of Color" IDS Task Force. Dermatol Pract Concept 2023;13:e2023067.
Dermoscopy in Skin of Color: The Journey So Far
https://dpcj.org/index.php/dpc/article/download/3622/2341
     Dermoscopy in Skin of Color: The Journey So Far
                             Enzo Errichetti1, Aimilios Lallas2, Giuseppe Argenziano3


1 Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Udine, Italy
2 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
3 Unit of Dermatology, Luigi Vanvitelli University of Campania, Naples, Italy



Key words: dermoscopy, dermatoscopy, epiluminescence, skin of color, dark skin, black skin, ethnic skin, dark phototype, african skin,
systematic review
Citation: Errichetti E, Lallas A, Argenziano G. Dermoscopy in Skin of Color: The Journey So Far. Dermatol Pract Concept. 2023;13(4)
S1:e2023305S. DOI: https://doi.org/10.5826/dpc.1304S1a305S
Accepted: June 19, 2023; Published: October 2023
Copyright: ©2023 Errichetti et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Enzo Errichetti, MD, Institute of Dermatology, “Santa Maria della Misericordia” University Hospital,
Piazzale Santa Maria della Misericordia, 15. 33100-Udine, Italy. Email: enzoerri@yahoo.it



Diagnosis in dermatology is a fascinating but also challeng-             overview about the use of dermoscopy in dark skin. Most of
ing process as it mostly relies on physician’s ability to identify       included data comes from four systematic reviews (one each
morphological details of elementary lesions [1, 2]. In the past,         for inflammatory, infectious, neoplastic and hair diseases) by
patients’ evaluation was mainly based on naked-eye clini-                the “Imaging in Skin of Color” Task Force of the Interna-
cal analysis, yet over the last few decades the additional use           tional Dermoscopy Society (IDS) [6-9], that has recently been
of the dermatoscope has been showed to increase diagnos-                 created. Inflammatory and infectious dermatoses turned out
tic accuracy, thereby deserving the epithet “dermatologist’s             to have the highest number of published articles (85 and 66,
stethoscope” [3]. Although initially used for supporting the             respectively), encompassing a total of 78 and 41 different
diagnosis of skin tumors, dermoscopic examination has been               conditions, likely as the result of the wider number of entities
extended to non-neoplastic conditions, especially inflamma-              in these fields and their high prevalence in dark-skinned pop-
tory and infectious dermatoses as well as hair diseases [4].             ulations [6,7]. Interestingly, trichoscopy showed the highest
Of note, albeit its use is wider in light phototypes (I-III),            ratio between published studies and number of diseases
dermoscopy has gained popularity also in dark-skinned pa-                (60 and 19, respectively) with consequent more data on re-
tients, in which patterns may significantly differ because of            producibility of the findings [8], unlike skin tumors that were
the darker background and specific reactions typical of skin             investigated by a limited number of studies (20 for a total
of color (e.g. lability of pigment and tendency to follicular or         of 46 neoplasms) possibly due to their lower prevalence in
sclerotic reactions) [5]. However, literature evidence on dark           skin of color [9]. Figure 1 depicts clinical subcategories of de-
phototypes is still limited (<3% of all published papers on              scribed dermatoses for each field (inflammatory, infectious,
dermoscopy) and sparse [6-9].                                            hair and neoplastic disorders), with the following conditions
    This special issue of Dermatology Practical & Concep-                being the most represented ones: (I) papulosquamous and
tual (DPC) provides the readers with an up-to-date literature            pigmentary dermatoses; (II) parasitoses (including bites and




Editorial | Dermatol Pract Concept. 2023;13(4)S1:e2023305S                                                                               1
Figure 1. Clinical subcategories of described dermatoses for each dermoscopic field (inflammatory, infectious, hair and neoplastic disorders);
the most represented ones include: (I) papulosquamous and pigmentary dermatoses; (II) parasitoses (including bites and stings), bacterial and
fungal diseases; (III) adnexal, keratinocytic and vascular tumors; and (IV) cicatricial and non-cicatricial alopecias.




stings), bacterial and fungal diseases; (III) adnexal, kerati-          with peaks in 2017 and 2021 for tumors, in 2019 for infec-
nocytic and vascular tumors; and (IV) cicatricial and non-­             tious dermatoses, and in 2020 for inflammatory disorders
cicatricial alopecias [6-9].                                            [6-9]. This is due to the increase of the absolute number of
    Moving to the temporal distribution of published articles           articles during such years but also to the publication of more
(Figure 2), while a more stable publication ratio per year was          comprehensive studies including a wider number of entities,
observed over the time for both hair diseases and tumors,               such as the multicentric controlled study on dermoscopy in
the number of articles on inflammatory and infectious der-              general dermatology promoted by the IDS in 2020 [5].
matoses showed a remarkable leap over the last few years,                    Notably, most of the available studies on dermoscopy of
with most papers being published during the last six years              dark phototypes showed a low level of evidence (V based
[6-9]. Regarding the number of newly described diseases                 on The Oxford 2011 Levels of Evidence), with a prevalence
(Figure 3), a significant increase was found in recent times,           of case-series and single case-reports and only a limited



2                                                                               Editorial | Dermatol Pract Concept. 2023;13(4)S1:e2023305S
       Figure 2. Temporal distribution of published articles on dermoscopy of dark-skinned patients; while a more stable publi-
       cation ratio per year was observed over the time for both hair diseases and tumors, the number of articles on inflammatory
       and infectious dermatoses showed a remarkable leap over the last few years, with most papers being published during the
       last six years.




       Figure 3. Temporal distribution of the number of dermatoses whose dermoscopic features were described for the first time;
       a significant increase was found in recent times, with peaks in 2017 and 2021 for tumors, in 2019 for infectious dermatoses,
       and in 2020 for inflammatory disorders.



Editorial | Dermatol Pract Concept. 2023;13(4)S1:e2023305S                                                                            3
Figure 4. Number of published articles according to the study type (cohort, case-control, case-series, and case-reports); inflammatory and
hair diseases display the greatest number of studies with a higher level of evidence (case-control and cross-sectional analyses), while articles
on infectious and neoplastic dermatoses are mainly case series and case reports




number of studies displaying a higher level of evidence, in-              homogeneous standardized nomenclature was provided in
cluding case-control and cross-sectional analyses (IV and                 the reviews based on the IDS dermoscopic criteria for tu-
III level of evidence, respectively) [6-9]. Interestingly, when           mors and non-neoplastic dermatoses validated for skin of
comparing the four included fields (Figure 4), inflamma-                  color [10,11]
tory and hair diseases turned out to have the greatest num-                   In conclusion, there is a growing interest towards the use
ber of studies with a higher level of evidence (11 and 21                 of dermoscopy in skin of color as testified by the recent in-
studies, respectively, taking into account both case-control              crease of the number of studies published in the literature on
and cross-sectional analyses), while articles on infectious               this topic. Such a supportive tool may have a relevant role in
and neoplastic dermatoses had a level of evidence of V (case              the context of the diagnostic process of dermatological dis-
­series/reports) in 98% (65 out of 66) and 90% (18 out of 20)             eases, that is even more complex in dark phototypes due to
of cases, respectively [6-9].                                             due to the lack of some important clinical clues, such as er-
    Finally, a poor consistency of used terminology among                 ythema, lesion shade or surface changes (e.g., pigmentation
the studies was also highlighted, especially for infectious/              and telangiectasias) [2]. However, analyses designed accord-
inflammatory dermatoses and tumors, with consequent                       ing to a systematic approach are needed to better validate the
limitations in terms of reproducibility of described find-                accuracy of this technique in skin of color and the present
ings [6, 7, 9]. To deal with such an issue, an alignment of               issue of DPC is intended to be the starting point to set new
dermoscopic terminology of reported features following a                  studies aiming at filling the highlighted gaps.




4                                                                                 Editorial | Dermatol Pract Concept. 2023;13(4)S1:e2023305S
References                                                                   review by the International Dermoscopy Society “Imaging
                                                                             in Skin of Color” Task Force. Dermatol Pract Concept. DOI:
1. Lallas A, Errichetti E, Ioannides D. Dermoscopy in General                10.5826/dpc.1304S1a309S
   ­Dermatology. Boca Raton, FL: CRC Press; 2018.                       8.   Khare S, Behera B, Ding DD, et al. Dermoscopy of Hair and
2. Errichetti E, Lallas A. Dermoscopy in General Dermatology for             Scalp Disorders (Trichoscopy) in Skin of Color – a systematic re-
    Skin of Color. Boca Raton, FL: CRC Press; 2021.                          view by the International Dermoscopy Society “Imaging in Skin
3. Lallas A, Argenziano G. Dermatoscope--the dermatologist’s                 of Color” Task Force. Dermatol Pract Concept. DOI: 10.5826
    stethoscope. Indian J Dermatol Venereol Leprol 2014;80:493-4.            /dpc.1304S1a310S
4. Errichetti E. Dermoscopy in General Dermatology (Non-                9.   Enechukwu NA, Behera B, Ding DD, et al. Dermoscopy of
    Neoplastic Dermatoses): The Journey So Far. Dermatol Ther                Cutaneous Neoplasms in Skin of Color – a systematic review
    (Heidelb) 2021;11:1871-7.                                                by the International Dermoscopy Society “Imaging in Skin of
5. Errichetti E, Ankad BS, Sonthalia S, et al. Dermoscopy in gen-            Color” Task Force. Dermatol Pract Concept. DOI: 10.5826
    eral dermatology (non-neoplastic dermatoses) of skin of colour:          /dpc.1304S1a308S
    a comparative retrospective study by the International Dermos-     10.   Errichetti E, Ankad BS, Jha AK, et al. International Dermoscopy
    copy Society. Eur J Dermatol 2020;30:688-98.                             Society criteria for non-neoplastic dermatoses (general dermatol-
6. Sławińska M, Żółkiewicz J, Behera B, et al. Dermoscopy of                 ogy): validation for skin of color through a Delphi expert con-
    ­Inflammatory Dermatoses (Inflammoscopy) in Skin of Color –              sensus. Int J Dermatol 2022;61:461-71.
     a systematic review by the International Dermoscopy Society       11.   Ankad BS, Behera B, Lallas A, et al. International Dermoscopy
     ­“Imaging in Skin of Color” Task Force. Dermatol Pract Concept.         Society (IDS) Criteria for Skin Tumors: Validation for Skin of
      DOI: 10.5826/dpc.1304S1a297S                                           Color Through a Delphi Expert Consensus by the “Imaging
7. Chauhan P, Behera B, Ding DD, et al. Dermoscopy of Infectious             in Skin of Color” IDS Task Force. Dermatol Pract Concept
      Dermatoses (Infectiouscopy) in Skin of Color – a systematic            2023;13:e2023067.




Editorial | Dermatol Pract Concept. 2023;13(4)S1:e2023305S                                                                                  5
