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The ABCD Rule of Dermatoscopy

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The ABCD Rule of Dermatoscopy The ABeD rule of dermatoscopy High prospective value in the diagnosis ofdoubtful melanocytic skin lesions Franz Nachbar, MD,a Wilhelm Stolz, MD,b Tanja Merkle, MD,a Armand B. Cognetta, MD,c Thomas Vogt, MD,b Michael Landthaler, MD,b Peter Bilek," Otto Braun-Falco, MD,a and Gerd Plewig, MDa Munich and Regensburg, Germany, and Tallahassee, Florida Background: The difficulties in accuratelyassessing pigmented skinlesions are ever present in practice. The recentlydescribed ABCD rule of dermatoscopy(skin surface microscopy at XIO magnification), based on the criteria asymmetry (A), border (B), color (C), and differential structure (D), improved diagnostic accuracy when applied retrospectively to clinical slides. Objective: A study was designed to evaluatethe prospectivevalueof the ABCD rule of der­ matoscopy in melanocyticlesions. Methods: In 172melanocytic pigmented skin lesions, the criteria of the ABeD rule of der­ matoscopy were analyzed with a semiquantitativescoring system before excision. Results:Accordingto the retrospectively determined threshold, tumors with a score higher than 5.45 (64/69 melanomas[92.8%]) wereclassified as malignant,whereas lesionswith a lowerscorewereconsideredas benign(93/103 melanocyticnevi [90.3%n.Negative predic­ tivevaluefor melanoma (True-Negative+ [True-Negative+ False-Negative)) was 95.8%, whereas positive predictive value (True-Positive+ [True-Positive + False-Positivel) was 85.3%. Diagnostic accuracy for melanoma (True-Positive + [True-Positive+ False­ Positive + False-Negative])was80.0%,comparedwith64.4% by the nakedeye. Melanoma showed a mean final dermatoscopy SCore of 6.79 (SD, ± 0.92), significantly differing from melanocytic nevi (mean score,4.27 ± 0.99; p < O.oI , U test), Conclusion: The ABeD rule can be easilylearned and rapidly calculated, and has proven to be reliable. Itshouldbe routinelyapplied to all equivocal pigmentedskin lesionsto reach a more objective and reproducible diagnosis and to obtain this assessment preoperatively. (J AM ACAD DERMATOL 1994;30:551-9.) Strong efforts to develop diagnostic criteria for microscopy produces a significant improvement in early detection ofmalignant melanoma (MM) have diagnostic accuracy of pigmented skin lesions.3-5 been fueled by the continuing increase in the inci­ Until recently, clinical application of skin surface dence of MM during the last decades. When com­ microscopy was hampered because inflexible and pared with clinical criteria alone, 1,2 skin surface expensive stereomicroscopes, which made the tech­ nique cumbersome and time consuming, had to be 3 5 From the Department of Dermatology, University ofMunich," The used. - These handicaps were overcome with the Department of Dermatology, UniversityofRegensburg.'' and Der­ development of the dermatoscope," which .allows matology Associates, Tallahassee." rapid surfacemicroscopic investigation. The derma­ Supported bya grant oftheGerman Minister ofResearch andTech­ nologyand the Deutsche Forschungsgemeinschaft (Sto 189/1-2). toscope is a hand-held instrument, similar to an oto­ Presented in partatthe Twentieth AnnualMeeting oftheGerman So­ scope, with a tubular body that at the top has an cietyof DermatologicalResearch,Nov. 13to15,1992,Mainz, Ger­ achromatic lens focused on a glass footplate provid­ many. ing a skin surface magnification of about XlO. Accepted for publication Sept. 7, 1993. Halogen illumination at an angle of 20 degrees is Reprint requests: Franz Nachbar, MD,Department ofDermatology, used with oil or disinfection solution applied to the University ofMunich Frauenlobstr. 9-11,0-80337 Miinchen,Ger­ many. skin to make the horny layer more translucent," Copyright ® 1994 by tbe American Academy of Dermatology, Inc. Numerous criteria i~ surface microscopy have 0190-9622/94 $3.00+ 0 16(1 (51325 been described- 8,9 that allow experienced observers 551 Journal of the American Academy of Dermatology 552 Nachbar et al. April 1994 Table I. Algorithm for distinguishing melanocytic assessed to yield a semiquantitative score. Asymmetry and nonmelanocytic pigmented lesions by was evaluated with respect to color and structure with dermatoscopy perpendicular axes chosen in such a way that the lowest asymmetry score possible is yielded. A score of 0 was Pathway steps Criteria for separation givenin case of symmetry in both axes, a score of I in case Easily Pigment network, regular streaks, of asymmetry in one axis, and a score of 2 in case of identifiable brown globules, steel-blue areas asymmetryin both axes (Fig. 1). For thecalculation ofthe melanocytic (blue nevus) border score the lesionswere divided into eight segments lesions as shown in Fig. 2. For each segment in which an abrupt Angiomatous Red lakes, homogeneous reddish or cutoff of .pigment pattern was present, one point was tumors and reddish black areas, well-defined added to the score. For the color score the number of col­ hemorrhages outline, lack of network, regular ors present within the lesion were counted (possible col­ streaks and globules ors: white, red, light and dark brown, blue-gray, and Pigmented Yellowish or white "comedo-like" black), leading to a minimum score of I and a maximum seborrheic openings, brownish gray of 6 (Fig. 3). Possible differential structural components keratoses appearance, well-defined outline, lack of network, regular streaks were network, homogeneous areas, dots, globules, and 5 and brown globules, presence of streaks (Fig. 4). Thus the differential structure score (D) teleangiectasias ranged from 1 to 5 points. Finally, the individual scores Pigmented Maple leaf-like areas, were multiplied by different weight factors obtained by basal cell telangiectases, lack of network, multivariate analysis.l? The weight factors followed by carcinomas regular streaks and globules the minimum and maximum scoresin parentheses are 1.3 Remaining Benign and malignant melanocytic for A (0, 2.6), 0.1 for B (0,0.8),0.5 for C (0.5, 3.0) and lesions lesions 0.5 for D (0.5,2.5). ThefinalABCD score was calculated Modified from Kreusch J, Rassner G. Hautarzt 1991;42:77-83. by adding the four individual scores (A through D), re­ sulting in a minimum final score of 1.0 (A = 0, B = 0, C = 1, D = 1) and a maximum of 8.9 (A = 2, B = 8, C =6, D = 5) (Table II). to discriminate between both melanocytic and non­ The results of the retrospective study showed that mel­ melanocytic skin lesions and between malignant and anocytic pigmented skin lesions could be differentiated benign melanocytic lesions. However, for novices into two diagnostic groups as follows: me1anocytic nevi correct interpretation of the images may be difficult (MN) if the final score was less than 5.45 and MM ifthe to learn. Therefore Stolz et al.!" introduced the score washigher than 5.45.Retrospective analysisshowed ABCD rule ofdermatoscopy, based on multivariate an early melanoma could not be completely excluded in analysis of only four criteria (asymmetry, abrupt all lesions with an ABCD score between 4.75 and 5.45. cutoff of the pigment pattern at the border, color Therefore these lesionswere excised. All lesionswere ex­ variegation, and different structure) with a semi­ amined by two independent dermatopathologists. quantitativescoresystem. The rulewas developed by Sensitivity (True-Positive -;- [True-Positive + False­ a retrospective analysis of color prints of dermato­ Positivej), specificity (True-Negative -;- [True-Negative + False-Positive]), negative predictive value (True-Neg­ scopic images at the same magnification seen under ative -;- [True-Negative + False-Negativejl.positivepre­ the dermatoscope. Inthe present study we tested the dictive value (True-Positive -;- [True-Positive + False­ ABCD rule prospectivelyto see whether determina­ Positivej) and diagnostic accuracy (True-Positive e­ tion of the criteria during examination of a lesion [True-Positive + False-Positive+ False-Negative]) for accurately predicts the correct diagnosis. both MM and MN were assessedto evaluate the predic­ tive valueof the ABCD rule.Themean scoresof MNand METHODS MM were compared by U test (p < 0.01) to detect A total of 194 pigmented skin lesionsconsecutively ex­ significant statistical differences between the scores. In cised between November 1991 and July 1992 were addition, mean scoresof dysplastic nevi,of nevi with signs included. Nonmelanocytic skin lesions were excluded by of inflammation, Spitz nevi,and nevi of the junctional or criteria previously recorded- 8 and listed in Table I. Re­ compound type were calculated as well as mean scores of maining melanocytic lesions were evaluated according to different types of MM. Pigmented skin lesions to which the ABCD rule of dermatoscopy. For the calculation of the ABCD rule was not applied before excisionwere not ABCD score the criteria of asymmetry (A), abrupt cut­ included in this study, nor were pigmented skin lesions off of the pigment pattern at the border (B), different col­ that were not histologically analyzed. During this study ors (C), and different structural components (D) were numerous lesionscould be clearly classifiedby dermatos- Journal of the American Academy of Dermatology Volume 30, Number 4 Nachbar et al. 553 B Fig. 1. Evaluation of asymmetry in melanocytic lesions A, Lackof asymmetry in both axes (asymmetry score = 0; compound nevus), A :::: 0, B = 0, C = 2, D = 3; ABCD score = 2.5. B,Asymmetryoflesion in one axis (asymmetryscore = l;MM).A = I,B = 8,C = 3,D = 4; ABCD score = 5.6. C, Asymmetry of lesion in two axes under angle of 90 degrees (asym­ metry score = 2; MM). A = 2, B
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