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General Dermatology): Validation for Skin of Color Through a Delphi Expert Consensus

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General Dermatology): Validation for Skin of Color Through a Delphi Expert Consensus Report International Dermoscopy Society criteria for non-neoplastic dermatoses (general dermatology): validation for skin of color through a Delphi expert consensus Enzo Errichetti1, MD, Balachandra S. Ankad2, MD, Abhijeet K. Jha3, MD, Sidharth Sonthalia4, MD, Bengu N. Akay5, MD, Roberto Bakos6, MD, Yasmeen J. Bhat7, MD, Manal Bosseila8, MD, Ralph Braun9, MD, Horacio Cabo10, MD, Emilia N. Cohen Sabban10, MD, Manas Chatterjee11, MD, Maryam Daneshpazhooh12, MD, Deepak Jakhar13, MD, Feroze Kaliyadan14, MD, Awatef Kelati15, MD, Vinay Keshavamurthy16, MD, Shekhar Neema17, MD, Ahmed Sadek18, MD, Gabriel Salerni19, MD, David L. Swanson20, MD, Trilokraj Tejasvi21, MD, Richard Usatine22, MD and Aimilios Lallas23, MD 1Institute of Dermatology, “Santa Maria Abstract della Misericordia” University Hospital, Background The International Dermoscopy Society (IDS) recently released a set of five 2 Udine, Italy, Department of Dermatology, basic dermoscopic parameters (vessels, scales, follicular findings, “other structures,” and Venereology and Leprosy, SN Medical specific clues) encompassing a total of 31 subitems to standardize the use of dermoscopy College, Bagalkot, Karnataka, India, 3Department of Dermatology & STD, Patna in non-neoplastic dermatoses, yet they have been developed taking into account Medical College & Hospital, Patna, India, Caucasian/Asian skin, with consequent possible limitations if used in dark skin. 4 Skinnocence, Skin Clinic & Research Objectives To validate the abovementioned criteria for the use in dark-skinned patients 5 Center, Gurugram, India, Department of (phototypes IV–VI) through an expert consensus. Dermatology, School of Medicine, Ankara Methods The two-round Delphi method was adopted, with an iterative process consisting University, Ankara, Turkey, 6Department of Dermatology, Hospital de Clınicas de Porto of two rounds of email questionnaires. Potential panelists were recruited via e-mail from all Alegre, Porto Alegre, Brazil, 7Department of over the world based on their expertise on dermoscopy of non-neoplastic dermatoses in Dermatology, Venereology and Leprology, skin of color. Government Medical College, University of Results Twenty-two panelists took part in the validation process. All of the five originally Kashmir, Srinagar, Jammu and Kashmir, proposed parameters and subitems reached agreement during the first round, aside from India, 8Dermatology Department, Cairo University, Cairo, Egypt, 9Department of “follicular red dots.” Additionally, during round 1, five new subitems were proposed Dermatology, University Hospital Zurich, (perifollicular scales distribution, follicular openings obliteration, broken hairs, eccrine 10 Zurich, Switzerland, Dermatology pigmentation, and eccrine ostia obliteration), along with the possibility to change the Department, Instituto de Investigaciones denomination of parameter 3 (from “follicular findings” to “follicular/eccrine findings”) and Medicas A. Lanari, University of Buenos split it into two subparameters (“follicular findings” and “eccrine findings”). All such Aires, Argentina, 11Department of Dermatology, Command Hospital (Eastern proposals reached agreement during the second round and therefore were included in the Command), Kolkata, India, 12Autoimmune final list, for a total of 37 items. Bullous Diseases Research Center, Tehran Conclusions Although nearly all the dermoscopic criteria originally proposed by the IDS University of Medical Sciences, Razi are applicable even to darker phototypes, several additional variables need to be Hospital, Tehran, Iran, 13Department of assessed. Dermatology, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India, 14Faculty of Dermatology, College of Medicine, Kind Faisal University, Al Ahsa, Saudi Arabia, 15Dermatology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco, 16Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, 1 ª 2021 the International Society of Dermatology International Journal of Dermatology 2021 2 Report IDS dermoscopic criteria in general dermatology in SOC Errichetti et al. Chandigarh, India, 17Department of Dermatology, Armed Forces Medical College, Pune, India, 18Department of Dermatology, Venereology and Andrology, Al-Azhar University Faculty of Medicine, Cairo, Egypt, 19Dermatology Department, Hospital Provincial del Centenario de Rosario, Universidad Nacional de Rosario, Argentina, 20Department of Dermatology, Mayo Clinic, Scottsdale, AZ, USA, 21Department of Dermatology, University of Michigan, Ann Arbor, MI, USA, 22Department of Dermatology and Cutaneous Surgery, Department of Family and Community Medicine, University of Texas Health San Antonio, San Antonio, TX, USA, and 23First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece Correspondence Enzo Errichetti, MD Institute of Dermatology “Santa Maria della Misericordia” University Hospital Piazzale Santa Maria della Misericordia 15. 33100-Udine Italy E-mail: [email protected] Conflict of interest: None. Funding source: None. The manuscript is an original unpublished work, and it is not submitted for publication elsewhere. All writers and contributors who participated in the preparation of the manuscript are listed as authors. There is no financial disclosure or conflict of interest. doi: 10.1111/ijd.15729 Introduction general dermatology. This consensus proposed a set of five basic dermoscopic parameters (with a total of 31 standardized Dermoscopy has gained significant appreciation in the field of subitems)1: (I) vessels (including morphology and distribution); non-neoplastic skin disorders (general dermatology), including (II) scales (including color and distribution); (III) follicular find- inflammatory, infectious, and infiltrative dermatoses, with many ings; (IV) “other structures” (structures other than vessels/ published studies over the last few years.1 However, dermo- scales; including color and morphology); and (V) “specific clues” scopic descriptions reported in the literature are often heteroge- (features that, when present, are strongly suggestive of only neous, metaphoric, and poorly comprehensible due to the lack one diagnosis because of a strict dermoscopic–pathological cor- of a systematic terminology and methodology of analysis.1 To relation). address this limitation, the International Dermoscopy Society Notably, the above-mentioned consensus document was (IDS) released a modified Delphi-based expert consensus docu- developed by experts dealing with Caucasian or Asian patients ment to be used as a guide for studies on dermoscopy in (generally with phototype up to IV),1 with consequent possible International Journal of Dermatology 2021 ª 2021 the International Society of Dermatology Errichetti et al. IDS dermoscopic criteria in general dermatology in SOC Report 3 limitations if used in darker-skinned patients.2 Indeed, it has Panelists were asked to judge on a 5-point scale the level of been demonstrated that dermoscopic patterns of dermatological agreement on the relevance of each variable for the use in diseases in skin of color (especially phototypes V/VI) may sig- dark-skinned patients (1, no agreement; 2, low agreement; 3, nificantly differ due to the diverse color background, specific moderate agreement; 4, agreement; and 5, strong agreement). reaction patterns in darker phototypes (e.g., lability of pigment In case of disagreement/poor agreement (score 1–3) on any of and greater tendency for follicular or sclerotic reactions), and the items, participants were invited to justify their choice and peculiar disorders exclusively or predominantly seen in dark (optional) provide suggestions to improve them. Experts were skin.2,3 This becomes even more relevant because the use of also given the opportunity to propose additional variables not dermoscopy for the evaluation of non-neoplastic dermatoses is included in the original list. Each item was considered as significantly expanding in dark-skinned populations, for which it appropriate for the use in skin of color if more than 80% of the has been classically used less due to the lower incidence of experts rated it with a score of 4 or 5 out of 5. Notably, the skin tumors.2 agreement threshold of 80% was chosen according to the The aim of this study was to validate the dermoscopic criteria literature recommendation on Delphi consensus.5 provided by the IDS for the use in skin of color by a consensus Variables not reaching 80% agreement would be modified process involving a panel of experts routinely dealing with dark- according to the provided feedback (if any) and redistributed, skinned patients (phototypes IV, V, and VI). along with new proposed items, to the panel of experts for round 2. Materials and methods Round 2 The consensus was performed based on the two-round Delphi In the second round, the panel of experts had to assess new method, with an iterative process consisting of two rounds of proposed items as well as variables not reaching agreement in email questionnaires starting from a list of preselected items the first round that had been modified according to the (i.e., dermoscopic criteria provided by the IDS).1 Such a feedback provided during the first step of the consensus procedure was chosen over the three-step modified Delphi process (if any). The same methods used in the first round method used in the original IDS consensus1 as the face-to-face
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