Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
In reply
Differences in cognitive processes, personal biases, and experiences probably shape differing views regarding the choice of dermoscopy algorithm preferred by any given individual. It is important to stress that despite the differing opinions being debated here, the treatment decisions, based on dermoscopic evaluations performed by physicians proficient in dermoscopy, remain the same regardless of the dermoscopic evaluation method used. With that being said, we will attempt to address some points raised by Kittler.
It is highly improbable for any dermoscopic algorithm to be without exceptions. Excluding dermatofibromas, we are aware of a few exceptions to the 2-step dermoscopy algorithm.1 - 2
Regarding the classification of lesions as melanocytic or nonmelanocytic, Kittler states that ink-spot lentigines are being incorrectly classified as melanocytic lesions via the 2-step algorithm. Although some ink-spot lentigines may be variants of solar lentigines (nonmelanocytic), others are variants of lentigo simplex (melanocytic).3 In the latter case, the first step of the 2-step algorithm is in fact classifying these lesions correctly.
It is important to stress that the issues being raised by Kittler pertain to the precision of the clinical diagnosis, which may or may not have any bearing on ultimate treatment. Although we should not stop striving toward clinical perfection, one should not lose sight of the ultimate aim, which is to perform a biopsy on all malignant neoplasms regardless of the leading clinical diagnosis.
Kittler highlights that in the occasional cases of pigmented Bowen disease lesions manifesting irregular dots and BCCs revealing streaks, there may result the incorrect classification of these lesions as melanocytic via the 2-step algorithm. However, both of these findings will result in melanoma entering the differential diagnosis, hence leading to a biopsy.
Even these examples are uncommon, since clinicians rely on more than dermoscopic morphologic traits in rendering a clinical diagnosis.4 The clinical features such as texture, consistency, and presence or absence of surface scale are all used in combination before a clinical diagnosis is rendered. For example, it is the concordance between the clinical features and the dermoscopic structures that help clinicians correctly identify lesions such as dermatofibromas. Furthermore, any given dermoscopic structure is not normally viewed in isolation but within the context of the other dermoscopic structures and clinical features present. In addition, knowledge of histopathology helps clinicians make sense of certain dermoscopic structures encountered in specific lesions. This places each structure in correct context, prevents misclassification of melanocytic and nonmelanocytic lesions, and assists in identifying collision tumors.
From our clinical, research, and teaching experiences, we believe that the 2-step algorithm is practical and reliable and easy to learn and apply. We acknowledge that multiple other “reliable” methods are at our disposal to evaluate lesions dermoscopically, including Kittler's pattern analysis approach.5 We agree completely with Kittler that all of these opinions need to be subjected to formal testing, some of which is in fact already under way through a study conducted by the International Dermoscopy Society. We remain optimistic that the results of this and other studies will further clarify this matter.
Correspondence: Dr Marghoob, Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 800 Veterans Memorial Hwy, Hauppauge, NY 11788 (marghooa@MSKCC.org).
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Archives of Dermatology editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.