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Original Investigation |

The Role of Color and Morphologic Characteristics in Dermoscopic Diagnosis

Shirin Bajaj, BA1,2; Michael A. Marchetti, MD1; Cristian Navarrete-Dechent, MD1,3; Stephen W. Dusza, DrPH1; Kivanc Kose, PhD1; Ashfaq A. Marghoob, MD1
[+] Author Affiliations
1Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
2Northwestern University, Feinberg School of Medicine, Chicago, Illinois
3Department of Dermatology, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
JAMA Dermatol. 2016;152(6):676-682. doi:10.1001/jamadermatol.2016.0270.
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Importance  Both colors and structures are considered important in the dermoscopic evaluation of skin lesions but their relative significance is unknown.

Objective  To determine if diagnostic accuracy for common skin lesions differs between gray-scale and color dermoscopic images.

Design, Setting, and Participants  A convenience sample of 40 skin lesions (8 nevi, 8 seborrheic keratoses, 7 basal cell carcinomas, 7 melanomas, 4 hemangiomas, 4 dermatofibromas, 2 squamous cell carcinomas [SCCs]) was selected and shown to attendees of a dermoscopy course (2014 Memorial Sloan Kettering Cancer Center dermoscopy course). Twenty lesions were shown only once, either in gray-scale (n = 10) or color (n = 10) (nonpaired). Twenty lesions were shown twice, once in gray-scale (n = 20) and once in color (n = 20) (paired). Participants provided their diagnosis and confidence level for each of the 60 images. Of the 261 attendees, 158 participated (60.5%) in the study. Most were attending physicians (n = 76 [48.1%]). Most participants were practicing or training in dermatology (n = 144 [91.1%]). The median (interquartile range) experience evaluating skin lesions and using dermoscopy of participants was 6 (13.5) and 2 (4.0) years, respectively.

Main Outcomes and Measures  Diagnostic accuracy and confidence level of participants evaluating gray-scale and color images. Two separate analyses were performed: (1) an unpaired evaluation comparing gray-scale and color images shown either once or for the first time, and (2) a paired evaluation comparing pairs of gray-scale and color images of the same lesion.

Results  In univariate analysis of unpaired images, color images were less likely to be diagnosed correctly compared with gray-scale images (odds ratio [OR], 0.8; P < .001). Using gray-scale images as the reference, multivariate analyses of both unpaired and paired images found no association between correct lesion diagnosis and use of color images (OR, 1.0; P = .99, and OR, 1.2; P = .82, respectively). Stratified analysis of paired images using a color by diagnosis interaction term showed that participants were more likely to make a correct diagnosis of SCC and hemangioma in color (P < .001 for both comparisons) and dermatofibroma in gray-scale (P < .001).

Conclusions and Relevance  Morphologic characteristics (ie, structures and patterns), not color, provide the primary diagnostic clue in dermoscopy. Use of gray-scale images may improve teaching of dermoscopy to novices by emphasizing the evaluation of morphology.

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Figure 1.
Plot of Predicted Marginal Probabilities of Correct Response for Gray-Scale and Color Image Assessments

A, Unpaired analysis. B, Paired analysis. A color image of squamous cell carcinoma was not included in unpaired image set; thus, there is no corresponding marginal probability of correct response for comparison to the gray-scale image.

aSignificantly higher or lower scores for color image assessment, in which P < .001.

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Figure 2.
Examples From Paired Color and Gray-Scale Dermoscopic Images

A and B, Multicolored dermatofibroma; 92.4% of participants correctly diagnosed it in gray-scale compared with 56.9% in color (P < .001). The most common incorrect answer for the color image was melanoma. C and D, the central white lines in this dermatofibroma are more conspicuous in gray-scale in which nearly double the participants were able to render a correct diagnosis (6.5% vs 15.0%, P = .03). E and F, The presence of a blue-white veil in this seborrheic keratosis likely led 44.1% of participants to incorrectly diagnose this as a melanoma. In gray-scale, this lesion was correctly diagnosed by 69.9% of participants (P = .01). G and H, Melanoma in which a nearly equal percentage of participants made the correct diagnosis in both images (85.5% vs. 86.8%, respectively, P = .74).

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