10.5826/dpc.1301a67
Introduction: A structured set of eight basic dermoscopic parameters (lines, clods, dots, circles, pseudopods, structureless, else, and vessels) including a total of 77 variables with corresponding descriptive and metaphoric vocabulary has been released for evaluation of skin tumors by the International Dermoscopy Society (IDS).
Objectives: To validate the aforementioned criteria for the use in darker phototypes (phototypes IV-VI) via an expert consensus.
Methods: The two-round “Delphi method” was adopted, with an iterative process including two rounds of email questionnaires. Potential panelists were asked to take part to the procedure via email on the basis of their expertise on dermoscopy of skin tumors in dark phototypes.
Results: A total of 17 participants were involved. All the original variables of the eight basic parameters reached agreement during the first round, except for “pink small clods” (“milky red globules”) and “structureless pink zone” (“milky red areas”). Moreover, during the first round, panelists proposed a change of three existing items and the introduction of four new items, i.e., “black, small clods” (“black globules”), “follicular plugs”, “erosions/ulcerations”, and “white color around vessels” (“perivascular white halo”). All such proposals achieved agreement, thus being included in the final list, for a total of 79 items. There was consistency between descriptive and metaphoric approach in terms of scoring.
Conclusions: Albeit most of the original items were considered applicable even for skin of color, there are some points of differences that physicians need to know. No significant preference was found between descriptive and metaphoric terminology among panelists.
text/xml
2160-9381
2927
en
Enzo Errichetti
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
tumors
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
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-10-19
2023-01-31
2023-02-27
e2023067
Dermatol Pract Concept
Introduction: A structured set of eight basic dermoscopic parameters (lines, clods, dots, circles, pseudopods, structureless, else, and vessels) including a total of 77 variables with corresponding descriptive and metaphoric vocabulary has been released for evaluation of skin tumors by the International Dermoscopy Society (IDS).
Objectives: To validate the aforementioned criteria for the use in darker phototypes (phototypes IV-VI) via an expert consensus.
Methods: The two-round “Delphi method” was adopted, with an iterative process including two rounds of email questionnaires. Potential panelists were asked to take part to the procedure via email on the basis of their expertise on dermoscopy of skin tumors in dark phototypes.
Results: A total of 17 participants were involved. All the original variables of the eight basic parameters reached agreement during the first round, except for “pink small clods” (“milky red globules”) and “structureless pink zone” (“milky red areas”). Moreover, during the first round, panelists proposed a change of three existing items and the introduction of four new items, i.e., “black, small clods” (“black globules”), “follicular plugs”, “erosions/ulcerations”, and “white color around vessels” (“perivascular white halo”). All such proposals achieved agreement, thus being included in the final list, for a total of 79 items. There was consistency between descriptive and metaphoric approach in terms of scoring.
Conclusions: Albeit most of the original items were considered applicable even for skin of color, there are some points of differences that physicians need to know. No significant preference was found between descriptive and metaphoric terminology among panelists.
Enzo Errichetti
2023/01/31
10.5826/dpc.1301a67
e2023067
Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Udine, Italy
2160-9381
tumors
en
e2023067
Blum A, Argenziano G. Metaphoric and descriptive terminology in dermoscopy: combine “blink” with “think”. Dermatol Pract Concept 2015; 5:23.
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
https://dpcj.org/index.php/dpc/article/download/2927/1949
 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
      Balachandra S Ankad1, Biswanath Behera2, Aimilios Lallas3, Bengu Nisa Akay4,
   Yasmeen J Bhat 5, Payal Chauhan6, Nkechi Anne Enechukwu7, Shamir Geller8, Abhijeet
  Kumar Jha9, Feroze Kaliyadan10, Kayitesi Kayitenkore11, Awatef Kelati12, Keshavamurthy
     Vinay13, Jennifer Stein14, Ibrahima Traoré15, Richard P Usatine16, Enzo Errichetti17


 1 Department of Dermatology, Venereology and Leprosy, SN Medical College, Bagalkot, Karna-taka, India
 2 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, India
 3 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
 4 Department of Dermatology, School of Medicine, Ankara University, Ankara, Turkey;
 5 Department of Dermatology, Venereology and Leprology, Government Medical College, University of Kashmir, Srinagar,
   Jammu and Kashmir, India
 6 Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Bilaspur, Himachal Pradesh, India
 7 Nnamdi Azikiwe University/Nnamdi Azikiwe Teaching Hospital Nnewi, Anambra State, Nigeria;
 8 Division of Dermatology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
 9 Department of Dermatology & STD, Patna Medical College & Hospital, Patna, India
10 Department of Dermatology, Sree Narayana Institute of Medical Sciences, Ernakulum, India
11 University of Rwanda, Kigali, Rwanda
12 Dermatology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS),
   Casablanca, Morocco
13 Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
14 The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
15 Dermatological clinic, Conakry, Guinea
16 Department of Dermatology and Cutaneous Surgery, Department of Family and Community Medicine, University of Texas Health San
   Antonio, San Antonio, TX, USA
17 Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Udine, Italy



Key words: dermoscopy, neoplasias, neoplastic dermatoses, skin of color, tumors
Citation: 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(1):e2023067.
DOI: https://doi.org/10.5826/dpc.1301a67
Accepted: November 17, 2022; Published: January 2023
Copyright: ©2023 Ankad 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, Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Piazzale Santa
Maria della Misericordia, 15. 33100-Udine, Italy. Tel: (+39) 0432559822. E-mail: enzoerri@yahoo.it




Original Article | Dermatol Pract Concept. 2023;13(1):e2023067                                                                                 1
    ABSTRACT        Introduction: A structured set of eight basic dermoscopic parameters (lines, clods, dots, circles, pseu-
                    dopods, structureless, else, and vessels) including a total of 77 variables with corresponding descrip-
                    tive and metaphoric vocabulary has been released for evaluation of skin tumors by the International
                    Dermoscopy Society (IDS).
                    Objectives: To validate the aforementioned criteria for the use in darker phototypes (phototypes
                    IV-VI) via an expert consensus.
                    Methods: The two-round “Delphi method” was adopted, with an iterative process including two
                    rounds of email questionnaires. Potential panelists were asked to take part in the procedure via email
                    on the basis of their expertise in the dermoscopy of skin tumors in dark phototypes.
                    Results: A total of 17 participants were involved. All the original variables of the eight basic p
                                                                                                                     ­ arameters
                    reached agreement during the first round, except for “pink small clods” (“milky red globules”) and
                    “structureless pink zone” (“milky red areas”). Moreover, during the first round, panelists proposed a
                    change of three existing items and the introduction of four new items, i.e., “black, small clods” (“black
                    globules”), “follicular plugs”, “erosions/ulcerations”, and “white color around vessels” (“perivascular
                    white halo”). All such proposals achieved agreement, thus being included in the final list, for a total
                    of 79 items. There was consistency between the descriptive and metaphoric approaches in terms of
                    scoring.
                    Conclusions: Albeit most of the original items were considered applicable even for skin of color, there
                    are some points of differences that physicians need to know. No significant preference was found
                    ­between descriptive and metaphoric terminology among panelists.




Introduction                                                      of darker phototypes (e.g., lability of pigment and greater
                                                                  tendency to follicular or sclerotic reactions) [6,7]. For these
Dermoscopy has nowadays become an invaluable tool                 reasons, the IDS supported a validation process of its con-
for the dermatologist’s daily practice as it allows to high-      sensus document on non-neoplastic dermatoses for use in
light relevant findings corresponding to key histological         dark skin, yet such a procedure has not been performed
changes that are not visible to the naked eye, thus increas-      with regard to neoplastic disorders [8].
ing diagnostic accuracy in the field of both neoplastic and          This document was promoted by the “Imaging in Skin
non-neoplastic skin conditions [1,2]. Importantly, to make        of Color” IDS Task Force with the aim of validating the
dermoscopic examination as reproducible as possible it            dermoscopic criteria/terminology provided by the IDS for
is of utmost importance to follow a systematic analytical         skin tumors for the use in skin of color by a consensus
approach, with a standardized set of parameters to evalu-         process involving a panel of experts routinely dealing with
ate and a uniform terminology to use [3-5]. However, over         dark-skinned patients (phototypes IV, V, and VI).
time, many authors employed an arbitrary approach with
the use of different terms, even to refer to the same dermo-
                                                                  Materials and Methods
scopic finding, with a consequent heterogeneous semeiol-
ogy generating confusion among users [4]. In order to face        The consensus was performed according to the two-round
such an issue, the International Dermoscopy Society (IDS)         “Delphi method”, with an iterative process including two
has released two consensus documents encompassing ba-             rounds of email questionnaires starting from a list of pre-
sic dermoscopic variables to assess with the corresponding        selected items (i.e., dermoscopic criteria provided by the
vocabulary to adopt, one for skin neoplasms and one for           IDS) [5]. Notably, differently from the “modified Delphi
non-neoplastic dermatoses (inflammatory, infectious, and          method”, the Delphi process makes it possible to gain expert
infiltrative diseases) [4,5]. Notably, these guidelines were      consensus on variable issues by using at least two rounds
issued considering the literature evidence on light photo-        of questionnaires and involving at least 5-10 participants,
types, with consequent possible limitations if used in dark       without the need for an in-person discussion [9-11]. So,
skin [4,5]. Indeed, it has been shown that dermoscopic            similarly to the validation process for skin of color carried
patterns of skin disorders may remarkably vary (espe-             out for non-neoplastic dermatoses [8], we chose to avoid a
cially for phototypes V/VI) because of the different color        face-to-face meeting in order to reduce decisional biases be-
backgrounds as well as specific reaction patterns typical         cause of group interaction [9-11].




2                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e2023067
Panel Selection                                                  by the unpaired, two-tailed student’s t-test, with p-value of
Panel selection was performed by sending an e-mail in-           <0.05 deemed statistically significant.
vitation from the coordinators of the process (E.E. and
B.S.A.) to experts in the field of dermoscopy in skin of         Results
color (phototypes IV, V, and VI) across the world. In de-
tail, all the members of the “Imaging in Skin of Color”          A total of 17 participants were involved in both rounds of
IDS Task Force were invited to join the panel, along with        the consensus. With regard to descriptive terminology, all the
researchers who had published at least five peer-reviewed        items received agreement in round 1 except for “pink small
articles or book chapters on such a topic as either the first    clods” and “structureless pink zone”, which reached a mean
or last author. In t­otal, 22 international experts were in-     score of 3.94 and 3.95, respectively. Similarly, corresponding
vited as panel members; participants’ assessments were           metaphoric terms for such variables (i.e., “milky red globules”
blinded and anonymity was maintained during the entire           and “milky red areas”) did not achieve agreement too, with a
process of consensus.                                            mean score of 3.98 and 3.86, respectively. Four new items were
                                                                 proposed during the first round, i.e., (I) “black, small clods”
Round 1                                                          (black globules) for parameter 2 (“CLODS”); (II) follicular

The dermoscopic criteria provided by the IDS [5] were tab-       plugs and (III) erosions/ulcerations for parameter 7 (“ELSE”);

ulated (Table 1) and shared with all the panelists via emails,   and (IV) white color around vessels (perivascular white halo)

including eight basic dermoscopic parameters with a total        for parameter 8 (“VESSELS”). Moreover, the group of experts

of 77 items. As per the original consensus, descriptive termi-   suggested changing three items when it comes to descriptive

nology and corresponding metaphoric vocabulary for each          terminology, including (I) “clods, brown or blue, concentric

dermoscopic parameter were included in the validation pro-       (clod within a clod)” to “clods, brown, blue or black, con-

cess. Instructions and aims of the consensus process were        centric (clod within a clod)”; (II) “dots, gray” to “dots, gray,

also circulated.                                                 blue or black”; and (III) “dots, gray and circles, gray” to “dots,

    Panelists were asked to judge on a 5-point scale the level   gray, blue or black and circles, gray, blue or black”.

of agreement on the relevance of each variable (descriptive         All such proposals were rated during the second round

and metaphoric) for the use in dark-skinned patients (1, no      and achieved agreement, thus being included in the final list.

agreement; 2, low agreement; 3, moderate agreement; 4,           Therefore, at the end of the validation process, a total of 79

agreement; and 5, strong agreement). In case of disagreement/    items were identified (72 out of the 77 proposed by the IDS

poor agreement (score 1-3) on any of the items, participants     plus seven added in the course of the consensus procedure).

were invited to justify their choice and provide (optional)      Table 1 displays details on agreement rates and mean scores

suggestions to improve them. Experts were also given the         for rounds 1 and 2. Figures 1-4 depict schematic illustrations

chance to propose additional variables not included in the       of the new/changed items and examples of skin tumors typi-

original list. Each item was considered appropriate for the      fied by such structures.

use in skin of color in case of achievement of a score of 4 or      Moving to the comparative analysis between descrip-

5 out of 5 by more than 80% of the experts. The agreement        tive and metaphoric terms of the eight basic parameters, al-

threshold of 80% was selected based on the literature guid-      though for the majority of them the mean score was higher

ance on Delphi consensus [10]. Parameters which had not          for the descriptive counterpart, no statistically significant

attained 80% agreement would be modified in accordance           differences were observed (p-values >0.05).

with suggestions (if any) given by the participants and re-
distributed, along with new possible proposed items, to the      Discussion
panel of experts for round 2.
                                                                 This expert consensus underlines that the whole set of dermo-
Round 2                                                          scopic criteria proposed by the IDS for the evaluation of skin
In round 2, panelists were asked to assess the modified and      tumors may also be used when assessing dark phototypes,
new parameters (if any) resulting from round 1, following        apart from “clods, pink and small” and “structureless zone,
the same methodology as the previous round. At the end of        pink” (and corresponding metaphoric terms, i.e., “milky-red
round 2, a comparison between the rating of descriptive and      globules” and “milky-red areas”) as “pink”/“milky-red” hue
metaphoric terminology for each of the eight basic dermo-        is more difficult to detect in skin of color because of the pig-
scopic parameters was carried out. Data were expressed as        mented background [6, 12].
means ± SD and analysis was performed using Microsoft               In general, most of the variables included from the orig-
Excel 2016 (Microsoft Corporation, Redmond, WA, USA)             inal IDS list (considering both descriptive and metaphoric




Original Article | Dermatol Pract Concept. 2023;13(1):e2023067                                                                   3
4
                                                                      Table 1. Results of the validation process for the use of the IDS dermoscopic criteria (including both descriptive and metaphoric terminology)
                                                                              for neoplastic dermatoses in skin of color with corresponding agreement rates (percentage of experts giving a score of 4 or 5)
                                                                                                                               and mean scores for each round

                                                                    Dermoscopic parameter (Descriptive terminology)               I Round*     II Round*   Dermoscopic parameter (Metaphoric terminology)   I Round*      II Round*
                                                                 1 Lines
                                                                  Lines, reticular                                                100 (4.83)       -       Pigment network                                  100 (4.91)        -
                                                                  Lines, reticular and thick                                      100 (4.75)       -       Broadened network                                100 (4.91)        -
                                                                  Lines, reticular and thin                                       100 (4.58)       -       Delicate network                                 100 (4.75)        -
                                                                  Lines, reticular and thick or reticular lines that vary in      100 (4.66)       -       Atypical pigment network                         100 (4.91)        -
                                                                  color
                                                                  Lines, reticular, white                                          85 (4.25)       -       -                                                     -            -
                                                                  Lines, reticular, hypopigmented, around brown clods              92 (4.41)       -       Negative pigment network                         100 (4.33)        -
                                                                  Lines, white, perpendicularly***                                100 (4.66)       -       Shiny white streaks***                           84.6 (4.66)       -
                                                                  Lines, branched                                                 100 (4.75)       -       Branched streaks                                 100 (4.66)        -
                                                                  Lines, radial (always at periphery)                             100 (4.83)       -       Streaks                                          100 (4.83)        -
                                                                  Lines, radial and segmental                                     100 (4.83)       -       Radial streaming                                 100 (4.66)        -
                                                                  Lines, radial, connected to a common base                       100 (4.75)       -       Leaflike areas                                   100 (4.83)        -
                                                                  Lines, radial, converging to a central dot or clod              100 (4.91)       -       Spoke wheel area                                 100 (4.75)        -
                                                                  Lines, curved and thick                                         100 (4.66)       -       Cerebriform pattern                              100 (4.83)        -
                                                                  Lines, brown, curved, parallel, thin                            100 (4.66)       -       Fingerprinting                                   100 (4.83)        -
                                                                  Lines, curved and thick, in combination with clods              100 (4.75)       -       Crypts                                           100 (4.83)        -
                                                                  Lines, parallel, short, crossing ridges (volar skin)            100 (4.83)       -       Fibrillar pattern                                100 (4.83)        -
                                                                  Lines, parallel, thick, on the ridges (volar skin)              100 (4.83)       -       Parallel ridge pattern                           100 (4.75)        -
                                                                  Lines, parallel, thin, in the furrows and crossing the ridges   100 (4.83)       -       Lattice-like pattern                             100 (4.75)        -
                                                                  (volar skin)
                                                                  Lines, parallel, thin, in the furrows (volar skin)              100 (4.83)       -       Parallel furrows pattern                         100 (4.75)        -
                                                                  Lines, angulated or polygonal (facial skin)                      92 (4.58)       -       Rhomboids/zig-zag pattern                         92 (4.50)        -
                                                                  Lines, angulated or polygonal (non-facial skin)                  92 (4.50)       -       Angulated lines/polygons                          92 (4.52)        -
                                                                 2 Clods
                                                                  Clods, small, round or oval                                     100 (4.75)       -       Globules                                         100 (4.50)        -
                                                                  Clods, brown, circumferential                                    92 (4.58)       -       Rim of brown globules                             92 (4.51)        -




Original Article | Dermatol Pract Concept. 2023;13(1):e2023067
                                                                    Dermoscopic parameter (Descriptive terminology)               I Round*     II Round*    Dermoscopic parameter (Metaphoric terminology)   I Round*       II Round*
                                                                  Clods, brown, yellow, or orange (rarely black)                   92 (4.52)       -        Comedo-like openings                              92 (4.41)          -
                                                                  Clods, brown or blue, concentric (clod within a clod)            85 (4.16)       -        Concentric globules                               92 (4.42)          -
                                                                  Clods, brown, blue or black, concentric (clod within a              -        100 (4.53)   Concentric globules                              100 (4.42)          -
                                                                  clod)**
                                                                  Clods, brown or skin colored, large and polygonal               100 (4.58)       -        Cobblestone pattern                              100 (4.50)          -
                                                                  Clods, blue, large, clustered                                   100 (4.52)       -        Blue-gray ovoid nests                            100 (4.75)          -
                                                                  Clods, blue, small                                              100 (4.41)       -        Blue globules                                    100 (4.41)          -
                                                                  Clods, black, small                                                 -        100 (4.53)   Black globules                                       -          100 (4.53)
                                                                  Clod within a clod (concentric clods)                            85 (4.25)       -        Variant of spoke wheel area                       85 (4.30)          -
                                                                  Clods, white, shiny***                                          100 (4.66)       -        Shiny white blotches and strands***              100 (4.56)          -
                                                                  Clods, pink and small                                            72 (3.94)       -        Milky-red globules                                72 (3.98)          -
                                                                  Clods, red or purple                                             92 (4.41)       -        Red lacunae                                       92 (4.23)          -
                                                                 3 Dots****




Original Article | Dermatol Pract Concept. 2023;13(1):e2023067
                                                                  Dots, any color                                                 100 (4.83)       -        Granularity or granules                           92 (4.54)          -
                                                                  Dots, gray                                                      100 (4.83)       -        Peppering                                         92 (4.52)          -
                                                                  Dots, gray, blue or black**                                         -        100 (5.0)    Peppering                                        100 (4.52)          -
                                                                  Dots, gray and circles, gray                                    100 (4.66)       -        Annular-granular pattern                         100 (4.58)          -
                                                                  Dots, gray, blue or black and circles, gray, blue or black**        -        100 (4.53)   Annular-granular pattern                         100 (4.58)          -
                                                                  Dots or clods, white, clustered or disseminated                  92 (4.58)       -        Milia-like cyst, cloudy or starry                100 (4.75)          -
                                                                  Dots, white, four arranged in a square***                       100 (4.51)       -        Rosettes***                                       92 (4.66)          -
                                                                  Dots, peripheral, arranged in lines                             100 (4.53)       -        Linear dots                                       85 (4.52)          -
                                                                  Dots, brown, central (in the center of hypopigmented             92 (4.48)       -        Targetoid dots                                    92 (4.32)          -
                                                                  spaces between reticular lines)
                                                                 4 Circles
                                                                  Circles, white                                                   92 (4.58)       -        -                                                    -               -
                                                                  Circles, concentric                                              92 (4.16)       -        Circle within a circle                            92 (4.16)          -
                                                                  Circles, incomplete                                              92 (4.33)       -        Asymmetric pigmented follicular openings         100 (4.12)          -
                                                                 5 Pseudopods
                                                                  Pseudopods, circumferential or lines, radial, circumferential   100 (4.66)       -        Starburst pattern                                100 (4.66)          -

                                                                                                                                                                                                                          Table 1 continues




5
6
                                                                      Table 1. Results of the validation process for the use of the IDS dermoscopic criteria (including both descriptive and metaphoric terminology)
                                                                              for neoplastic dermatoses in skin of color with corresponding agreement rates (percentage of experts giving a score of 4 or 5)
                                                                                                                        and mean scores for each round (continued)

                                                                    Dermoscopic parameter (Descriptive terminology)           I Round*     II Round*    Dermoscopic parameter (Metaphoric terminology)   I Round*     II Round*
                                                                 6 Structureless
                                                                   Structureless zone, brown or black                         100 (4.75)       -        Blotch                                           100 (4.75)       -
                                                                   Structureless zone, blue                                   100 (4.58)       -        Blue-whitish veil                                100 (4.66)       -
                                                                   Structureless zone, pink                                    75 (3.95)       -        Milky-red areas                                   72 (3.86)       -
                                                                   Structureless zone, white                                  100 (4.83)       -        Scar-like depigmentation                         100 (4.75)       -
                                                                   Structureless zone, white, central                         100 (4.83)       -        Central white patch                              100 (4.66)       -
                                                                   Structureless zone, polychromatic                           85 (4.33)       -        Rainbow pattern                                   92 (4.41)       -
                                                                   Structureless, red, interrupted by follicular openings      82 (4.16)       -        Strawberry pattern                                85 (4.23)       -
                                                                   Structureless, brown (tan), eccentric                      100 (4.58)       -        -                                                    -            -
                                                                   Structureless, any color                                   100 (4.75)       -        Homogeneous pattern                              100 (4.83)       -
                                                                   Structureless, brown, interrupted by follicular openings   100 (4.66)       -        Pseudonetwork                                    100 (4.66)       -
                                                                   (facial skin)
                                                                 7 Else
                                                                   Sharply demarcated, scalloped border                       100 (4.66)       -        Moth-eaten border                                100 (4.75)       -
                                                                   Follicular plugs                                               -        92 (4.69)    -                                                    -            -
                                                                   Erosions/Ulcerations                                           -        100 (4.84)   -                                                    -            -
                                                                 8 Vessels
                                                                   8.1 Morphology
                                                                       Dots                                                   100 (4.75)       -        -                                                    -            -
                                                                       Clods                                                  100(4.38)        -        Red-purple lacunes                               100 (4.46)       -
                                                                       Linear                                                 100 (4.75)       -        -                                                    -            -
                                                                       Coiled                                                 100 (4.58)       -        Glomerular                                       100 (4.50)       -
                                                                       Looped                                                 100 (4.66)       -        Hairpin                                          100 (4.75)       -
                                                                       Serpentine                                             100 (4.50)       -        Linear irregular                                 100 (4.58)       -
                                                                       Helical                                                100 (4.50)       -        Corkscrew                                        100 (4.58)       -
                                                                       Curved                                                 100 (4.44)       -        Comma                                            100 (4.41)       -
                                                                       Monomorphous                                            92 (4.41)       -        -                                                    -            -
                                                                       Polymorphous                                           100 (4.75)       -        -                                                    -            -




Original Article | Dermatol Pract Concept. 2023;13(1):e2023067
                                                                      Dermoscopic parameter (Descriptive terminology)                       I Round*         II Round*          Dermoscopic parameter (Metaphoric terminology)                       I Round*          II Round*
                                                                     8.2 Arrangement
                                                                        Radial                                                             100 (4.66)              -           Crown vessels                                                          92 (4.50)             -
                                                                        Serpiginous                                                        100 (4.66)              -           String of pearls                                                      100 (4.66)             -
                                                                        Branched                                                           100 (4.78)              -           Arborizing vessels                                                    100 (4.83)             -
                                                                        Clustered                                                          100 (4.83)              -           -                                                                          -                 -
                                                                        Centered dots                                                      100 (4.61)              -           Targetoid vessels                                                     100 (4.63)             -
                                                                     8.3 White color around vessels                                              -           100 (4.53)        Perivascular white halo                                                    -           100 (4.61)

                                                                 * Agreement rate (mean score) – Agreement rate is measured from 0% to 100%, mean score is measured from 0 to 5;
                                                                 ** This parameter replaces the previous one.
                                                                 *** Only visible by polarized dermoscopy.
                                                                 **** Dots and clods can be best differentiated if they appear as a pattern. Multiple dots have the same size and shape (they are all small and round), multiple clods vary in size and shape. In general dots are not
                                                                 7
                                                                 larger than the diameter of a terminal hair.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023067
7
    Figure 1. Schematic representation of newly-introduced dermoscopic parameters to use in skin of color: black, small clods (black
    globules) (a); follicular plugs (b); erosions/ulcerations (c); and white color around vessels (perivascular white halo) (d).



terminology) received a high mean rate (between 4.5 and 5),           change in the morphology of some structures (e.g., “incom-
with only a few of them reaching agreement with a lower               plete” may become “complete” pigmented circles). This is in
score (< 4.5). In detail, the latter group included the follow-       line with evidence from the literature. For example, blurred
ing descriptive items: “reticular white lines” and “lines, retic-     vascular structures and “reticular white lines”/“lines, reticu-
ular, hypopigmented, around brown clods” in the “LINES”               lar, hypopigmented, around brown clods” (negative pigment
category; “clods, brown or blue, concentric (clod within a            network), commonly found respectively in dermal nevi and
clod)”, “clods, blue, small”, “clod within a clod (concentric         dermatofibromas in light phototypes, have been reported
clods)” and “clods, red or purple” in the “CLODS” param-              less frequently in skin of color [13-15].
eter; “dots, brown, central (in the center of hypopigmented               On the other hand, homogeneous pigmentary findings
spaces between reticular lines)” in the “DOTS” category;              (excluding concentric and polychromatic items) and white
“circles, concentric” and “circles, incomplete” when it comes         structures were generally rated high (> 4.5). This is easily
to the “CIRCLES” parameter; “structureless zone, poly-                explained as diagnosis of skin tumors in dark-skinned pa-
chromatic” and “structureless, red, interrupted by follicular         tients mainly relies on the prevalence and combination of
openings” considering the “STRUCTURELESS” category;                   such features [16]. Additionally, some vessel shapes/arrange-
and “clods”, “curved” and “monomorphous” morphol-                     ments also reached a high score, especially dotted/linear
ogy in the “VESSELS” parameter. The reasons underlying a              morphologies and clustered/branched distribution patterns,
lower scoring for such variables mainly include the higher            likely resulting from the significant prevalence of these find-
melanin content and the greater tendency to pigmentary in-            ings in Bowen’s disease and basal cell carcinoma also in skin
continence typical of darker phototypes [6] that may result           of color [17, 18].
in lower optical contrast (needed to optimally see concen-                Besides dermoscopic items included in the original list of
tric, polychromatic or pigmented structures) or the partial           the IDS, panelists also proposed and agreed on the introduc-
obscuration of some findings (e.g., red/purple structures,            tion of four new variables for the assessment of skin tumors
smaller/thinner vessels, or hypopigmented lines) as well as           in dark phototypes, including “clods, black, small” (black



8                                                                         Original Article | Dermatol Pract Concept. 2023;13(1):e2023067
          Figure 2. Examples of skin tumors in dark-skinned patients (phototypes V/VI) typified by the newly-introduced dermo-
          scopic structures: black, small clods (black globules) in a seborrheic keratosis (arrows) (a); follicular plugs in an actinic
          keratosis (arrows) (b); erosions in a basal cell carcinoma (arrows) (c); and white color around vessels (perivascular white
          halo) in a squamous cell carcinoma (d).




Figure 3. Schematic representation of modified dermoscopic parameters to use in skin of color: “clods, brown, blue or black, concen-
tric” (clod within a clod) (a); “dots, gray, blue or black” (peppering) (b); and “dots, gray, blue or black and circles, gray, blue or black”
(annular-granular pattern) (c).




Figure 4. Examples of skin tumors in dark-skinned patients (phototypes V/VI) typified by the modified dermoscopic parameters: black/
brown concentric clods (black clod within a brown clod) in a basal cell carcinoma (arrows) (a); “blue/black dots” (blue/black peppering) in a
melanoma (arrows) (b); and “blue/black dots and circles” (blue/black annular-granular pattern) in a lentigo maligna (arrows) (c).



Original Article | Dermatol Pract Concept. 2023;13(1):e2023067                                                                             9
globules), follicular plugs, erosions/ulcerations, and white         intended to be the starting point to fill the existing knowl-
color around vessels (perivascular white halo), histologically       edge gap in the field of dermoscopy of skin tumors in skin of
related to melanin deposits/melanocytes in the epidermis,            color as it might help facilitate the interpretation of reported
follicular hyperkeratosis, loss of epidermis/dermis, and ac-         findings and increase the reproducibility of the studies.
anthosis, respectively. This was due to their significant diag-
nostic relevance (e.g., follicular plugs are a key clue in actinic   Limitations
keratosis/SCC as they often show a pigmentary pattern sim-           The present validation process was based on the Delphi tech-
ilar to lentigo maligna/melanoma – see Figures 2b,4c) but            nique, which relies on the opinion of a group of experts, so
also to the higher prevalence of such structures in skin of          the results represent the point of view of a limited number
color (as the result of a greater tendency to darker pigmen-         of evaluators. Additionally, albeit all the included panelists
tation and follicular/ulcerative reactions as well as a greater      routinely deal with dark-skinned patients, an interobserver
contrast between the perivascular white halo and surround-           variability does exist in terms of the proportions of each
ing pigmented skin) [6, 19]. Moreover, during the consensus          phototype.
process a change of three existing parameters (i.e., “dots”,
“clod within a clod”, and “dots and circles”) was also in-
                                                                     References
cluded, with darker colors (blue/black) being listed as a pos-
sible additional hue for the aforementioned structures, still         1. Errichetti E, Stinco G. Dermoscopy in General Dermatology: A
                                                                         Practical Overview. Dermatol Ther (Heidelb) 2016;6:471-507.
due to the higher tendency to have more prominent pigmen-
                                                                      2. Fee JA, McGrady FP, Rosendahl C, Hart ND. Training Primary
tation in dark phototypes [6, 19].
                                                                         Care Physicians in Dermoscopy for Skin Cancer Detection: a
     Finally, the comparative analysis between descriptive and           Scoping Review. J Cancer Educ 2020;35:643-50.
metaphoric terminology highlighted no relevant differences            3. Errichetti E. Dermoscopy of Inflammatory Dermatoses (Inflam-
in terms of mean score for each of the eight basic parameters,           moscopy): An Up-to-Date Overview. Dermatol Pract Concept
thereby underlying that both of them are useful and might be             2019;9:169-80.
                                                                      4. Errichetti E, Zalaudek I, Kittler H, et al. Standardization of
complementary. In fact, the metaphoric approach is more re-
                                                                         dermoscopic terminology and basic dermoscopic parameters to
lated to “blink” (quick) diagnoses (e.g., “arborizing” vessels
                                                                         evaluate in general dermatology (non-neoplastic dermatoses): an
are a quick hint for a basal cell carcinoma), while descriptive          expert consensus on behalf of the International Dermoscopy So-
assessment is extremely helpful when “blink” fails in describ-           ciety. Br J Dermatol 2020;182:454-67.
ing a lesion and a more analytical process is needed for a            5. Kittler H, Marghoob AA, Argenziano G, et al. Standardization of
correct dermoscopic diagnosis [20, 21]. The lack of a clear              terminology in dermoscopy/dermatoscopy: Results of the third
                                                                         consensus conference of the International Society of Dermos-
predominance between the two approaches is also empha-
                                                                         copy. J Am Acad Dermatol 2016;74:1093-106.
sized by the consistency observed in the present consensus
                                                                      6. Errichetti E, Ankad BS, Sonthalia S, et al. Dermoscopy in gen-
process when considering the rating of each descriptive item             eral dermatology (non-neoplastic dermatoses) of skin of colour:
and corresponding metaphoric counterpart (<4.0; 4÷4.5;                   a comparative retrospective study by the International Dermos-
>4.5), with the only exception of “comedo-like openings”.                copy Society. Eur J Dermatol 2020;30:688-98.
Indeed, this item was rated lower than the corresponding              7. Errichetti E. Dermoscopy of common papulosquamous derma-
                                                                         toses varies between dark (III and IV) and very dark (V and VI)
descriptive terminology, likely because it has a weaker cor-
                                                                         skin phototypes. Dermatol Ther 2021;34:e14757.
respondence from a morphological point of view in skin of
                                                                      8. Errichetti E, Ankad BS, Jha AK, et al. International Dermoscopy
color as the lower optical contrast typical of dark phototypes           Society criteria for non-neoplastic dermatoses (general dermatol-
often makes epidermal invaginations filled with keratin look             ogy): validation for skin of color through a Delphi expert con-
like darkly pigmented globules rather than “comedo-like                  sensus. Int J Dermatol 2022;61:461-71.
openings” [12].                                                       9. Hasson F, Keeney S, McKenna H. Research guidelines for the
                                                                         Delphi survey technique. J Adv Nurs 2000;32:1008-15.
                                                                     10. Lynn MR. Determination and quantification of content validity.
Conclusions                                                              Nurs Res 1986;35:382-5.
                                                                     11. Graefe A, Armstrong JS. Comparing face-to-face meetings, nomi-
To conclude, the present validation process provides struc-              nal groups, Delphi and prediction markets on an estimation task.
tured dermoscopic criteria for the assessment of skin tumors             Int J Forecasting 2016;27:183-95.
in dark phototypes based on parameters proposed by the               12. Ankad BS, Sakhare PS, Prabhu MH. Dermoscopy of
                                                                         non-melanocytic and pink tumors in brown skin: A descriptive
IDS. Albeit most of the original items were considered appli-
                                                                         study. Indian J Dermatopathol Diagn Dermatol 2017;4:41-51.
cable even for skin of color, there are some points of differ-
                                                                     13. Lallas A, Reggiani C, Argenziano G, et al. Dermoscopic nevus
ences that physicians need to know. Notably, no significant              patterns in skin of colour: a prospective, cross-sectional, mor-
preference was found between descriptive and metaphoric                  phological study in individuals with skin type V and VI. J Eur
terminology. The set of criteria validated in this consensus is          Acad Dermatol Venereol 2014;28:1469-74.



10                                                                        Original Article | Dermatol Pract Concept. 2023;13(1):e2023067
14. Sarma N, Das A, Gupta A. Melanocytic nevus and Nevoid dis-           18. Behera B, Kumari R, Thappa DM, Gochhait D, Srinivas BH,
    orders. In: Dermoscopy histopathology correlation (Ankad BS,             Ayyanar P. Dermoscopy of Bowen’s disease: A case series
    Mukherjee SS, Nikam BP, eds), 1st edn. Singapore: Springer               of five patients. Indian J Dermatol Venereol Leprol 2021;
    ­Publications, 2021:15-46.                                               87:576-80.
15. Kelati A, Aqil N, Baybay H, et al. Beyond classic dermoscopic        19. Neema S, Patil S, Pol D. Basic Principles of Dermoscopy. In:
     patterns of dermatofibromas: a prospective research study. J Med        IADVL Atlas of Dermoscopy (Ankad BS, Bhat YJ, Rambhia
     Case Reports 2017;11:266.s                                              KD, eds), 1 edn. New Delhi: Jaypee Brothers Medical Publishers,
16. Ezenwa E, Stein JA, Krueger L. Dermoscopic features of neo-              2022:6-18.
     plasms in skin of color: A review. Int J Womens Dermatol            20. Giacomel J, Zalaudek I, Marghoob AA. Metaphoric and descrip-
     2021;7:145-51.                                                          tive terminology in dermoscopy: lessons from the cognitive sci-
17. Vinay K, Ankad BS, Narayan VR, et al. A multicentric study on            ences. Dermatol Pract Concept 2015; 5:69-74.
     dermoscopic patterns and clinico-dermoscopic-histological cor-      21. Blum A, Argenziano G. Metaphoric and descriptive terminology
     relates of basal cell carcinoma in Indian skin. Clin Exp Dermatol       in dermoscopy: combine “blink” with “think”. Dermatol Pract
     2022 Jul 22. doi: 10.1111/ced.15337.                                    Concept 2015; 5:23.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023067                                                                          11
