Two-step-7-Pink Rule: A Practical Tool for the Dermoscopic Evaluation of Fully Amelanotic Skin Lesions

Two-step-7-Pink Rule: A Practical Tool for the Dermoscopic Evaluation of Fully Amelanotic Skin Lesions

Authors

  • Riccardo Pampena Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Skin Cancer Center, Reggio Emilia, Italy
  • Stefano Migliorati Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Skin Cancer Center, Reggio Emilia, Italy
  • Giovanni Paolino IRCCS Ospedale, San Raffaele, Milano, Italy
  • Michela Lai Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
  • Nicola Lippolis Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Skin Cancer Center, Reggio Emilia, Italy
  • Stefania Guida School of Medicine, Vita-Salute San Raffaele University, Milano, Italy
  • Stefania Borsari Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Skin Cancer Center, Reggio Emilia, Italy
  • Sebastiano Pellerone Dermatology Unit, University of Campania, Naples, Italy
  • Sofia Maria Di Ciaccio Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
  • Elvira Moscarella Dermatology Unit, University of Campania, Naples, Italy
  • Giovanni Pellacani Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
  • Giuseppe Argenziano Dermatology Unit, University of Campania, Naples, Italy
  • Caterina Longo Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Skin Cancer Center, Reggio Emilia, Italy

Keywords:

melanoma, fully-amelanotic skin tumours, pink lesions, dermoscopy

Abstract

Introduction: The diagnosis of fully amelanotic skin tumors is difficult on clinical and dermoscopic examination.

Objective: We sought to identify an accurate and user-friendly dermoscopic algorithm to differentiate between benign and malignant pink lesions.

Methods: The database of 1 referral center was retrospectively reviewed for images of non-inflammatory fully amelanotic skin lesions. Two dermatologists jointly assessed a validation set of images for dermoscopic criteria and constructed a diagnostic algorithm, the 2-step 7-pink rule (2S-7PR). Two external clinicians, with different skills in dermoscopy and blinded to the final diagnosis, separately evaluated images from the validation test sets using the prevalent criterion method and the new 2S-7PR algorithm.

Results: A total of 763 lesions from 652 patients were included in the validation set database, of which 68.3% were malignant and 31.7% were benign. Three suspicious dermoscopic criteria were included in the first step of the 2S-7PR: polymorphous or sharply focused vessels, scales or crusts, and erosions or ulcerations; and 4 non-suspicious criteria were included in the second: white collarette, white scar-like area, vascular lacunae, and necklace pinpoint vessels. High levels of specificity and sensitivity were calculated in the validation and test phases for both the expert and non-expert evaluators, the former achieving higher levels of both sensitivity and specificity by employing the 2S-7PR compared to the prevalent method, and the latter only improved specificity.

Conclusions: The present study showed that an algorithm focused on a few reproducible and easily recognizable criteria could improve diagnostic accuracy in the management of amelanotic lesions.

References

Menzies SW, Kreusch J, Byth K, et al. Dermoscopic evaluation of amelanotic and hypomelanotic melanoma. Arch Dermatol. 2008;144(9):1120-1127. DOI:10.1001/archderm.144.9.1120. PMID: 18794455.

Mascolo M, Russo D, Scalvenzi M, Varricchio S, Staibano S. Pitfalls in the dermoscopic diagnosis of amelanotic melanoma. J Am Acad Dermatol. 2015;72(1 Suppl):S2-S3. DOI:10.1016/j.jaad.2014.02.040. PMID: 25500029.

Jaimes N, Braun RP, Thomas L, Marghoob AA. Clinical and dermoscopic characteristics of amelanotic melanomas that are not of the nodular subtype. J Eur Acad Dermatol Venereol. 2012;26(5):591-596. DOI:10.1111/j.1468-3083.2011.04122.x. PMID: 21585561

Sbano P, Nami N, Grimaldi L, Rubegni P. True amelanotic melanoma: the great masquerader. J Plast Reconstr Aesthet Surg. 2010;63(3):e307-308. DOI:10.1016/j.bjps.2009.07.009. PMID: 19713163

Russo T, Piccolo V, Lallas A, et al. Dermoscopy of Malignant Skin Tumours: What’s New? Dermatology. 2017;233(1):64-73. DOI:10.1159/000472253. PMID: 28486238

Geller S, Pulitzer M, Brady MS, Myskowski PL. Dermoscopic assessment of vascular structures in solitary small pink lesions-differentiating between good and evil. Dermatol Pract Concept. 2017;7(3):47-50. DOI:10.5826/dpc.0703a10. PMID: 29085720

Pizzichetta MA, Talamini R, Stanganelli I, et al. Amelanotic/hypomelanotic melanoma: clinical and dermoscopic features. Br J Dermatol. 2004;150(6):1117-1124. DOI:10.1111/j.1365-2133.2004.05928.x. PMID: 15214897

Ferrara G, Gianotti R, Cavicchini S, Salviato T, Zalaudek I, Argenziano G. Spitz nevus, Spitz tumor, and spitzoid melanoma: a comprehensive clinicopathologic overview. Dermatol Clin. 2013;31(4):589-598, viii. DOI:10.1016/j.det.2013.06.012. PMID: 24075547

Zaballos P, Carulla M, Ozdemir F, et al. Dermoscopy of pyogenic granuloma: a morphological study. Br J Dermatol. 2010;163(6):1229-1237. DOI:10.1111/j.1365-2133.2010.10040.x. PMID: 20846306

Zalaudek I, Argenziano G, Kerl H, Soyer HP, Hofmann-Wellenhof R. Amelanotic/Hypomelanotic melanoma--is dermatoscopy useful for diagnosis? J Dtsch Dermatol Ges. 2003;1(5):369-373. DOI:10.1046/j.1610-0387.2003.02042.x. PMID: 16285302

Pizzichetta MA, Kittler H, Stanganelli I, et al. Dermoscopic diagnosis of amelanotic/hypomelanotic melanoma. Br J Dermatol. 2017;177(2):538-540. DOI:10.1111/bjd.15093. PMID: 27681347

Rosendahl C, Tschandl P, Cameron A, Kittler H. Diagnostic accuracy of dermatoscopy for melanocytic and nonmelanocytic pigmented lesions. J Am Acad Dermatol. 2011;64(6):1068-1073. DOI:10.1016/j.jaad.2010.03.039. PMID: 21440329

Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricalà C, Argenziano G. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part I. Melanocytic skin tumors. J Am Acad Dermatol. 2010;63(3):361-374; quiz 375-376. DOI:10.1016/j.jaad.2009.11.698. PMID: 20708469

Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricalà C, Argenziano G. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors. J Am Acad Dermatol. 2010;63(3):377-386; quiz 387-388. DOI:10.1016/j.jaad.2009.11.697. PMID: 20708470

Argenziano G, Zalaudek I, Corona R, et al. Vascular structures in skin tumors: a dermoscopy study. Arch Dermatol. 2004;140(12):1485-1489. DOI:10.1001/archderm.140.12.1485. PMID: 15611426

Giacomel J, Zalaudek I. Pink lesions. Dermatol Clin. 2013;31(4):649-678, ix. DOI:10.1016/j.det.2013.06.005. PMID: 24075552

Russo T, Pampena R, Piccolo V, et al. The prevalent dermoscopic criterion to distinguish between benign and suspicious pink tumours. J Eur Acad Dermatol Venereol. 2019;33(10):1886-1891. DOI:10.1111/jdv.15707. PMID: 31125473

Sinz C, Tschandl P, Rosendahl C, et al. Accuracy of dermatoscopy for the diagnosis of nonpigmented cancers of the skin. J Am Acad Dermatol. 2017;77(6):1100-1109. DOI:10.1016/j.jaad.2017.07.022. PMID: 28941871

Paolino G, Bearzi P, Pampena R, et al. Clinicopathological and dermoscopic features of amelanotic and hypomelanotic melanoma: a retrospective multicentric study. Int J Dermatol. 2020;59(11):1371-1380. doi: 10.1111/ijd.15064. Epub 2020 Jul 29. PMID: 32726478.

Published

2025-01-29

How to Cite

1.
Pampena R, Migliorati S, Paolino G, et al. Two-step-7-Pink Rule: A Practical Tool for the Dermoscopic Evaluation of Fully Amelanotic Skin Lesions. Dermatol Pract Concept. 2025;15(1):4768. doi:10.5826/dpc.1501a4768

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