Mole Examination with Dermatoscopy in Ankara, Turkey

Mole examination with dermatoscopy is a non-invasive diagnostic method used to examine the structural features of moles (nevi) on the skin in detail. Thanks to a special optical device called a dermatoscope, the color, borders, and internal structure of the mole are magnified and evaluated. In this way, early-stage skin cancers can be detected.

Dermatoscopic examination provides high accuracy in distinguishing melanocytic and non-melanocytic lesions. Pigment distributions, vascular structures, and sublayer features that cannot be noticed by visual examination are analyzed in detail through the dermatoscope. This method also helps prevent unnecessary biopsies.

Dermatoscopy is of great importance in the follow-up of moles. Moles that show changes in color, shape, or size over time should be checked dermatoscopically at regular intervals. Thanks to digital dermatoscopy systems, comparisons can be made with previous images, which increases the possibility of early diagnosis.

No pain or discomfort is felt during the examination; the procedure is completely painless and short. Professional evaluation performed by a dermatologist is of vital importance for the early diagnosis of serious skin diseases such as malignant melanoma. Regular dermatoscopy controls are an effective screening method in preserving skin health.

How does the dermatoscopy device work and how does it show the inside of a mole?

The whole secret of this technology is eliminating the light reflection and glare coming from the outermost layer of the skin. Normally, when we look at a mole, the surface of the skin reflects light like a mirror and this prevents us from seeing the actual structure underneath. A dermatoscope, however, “breaks” this glare and makes the skin almost transparent.

To do this, two basic illumination methods are used, and it is very important for a doctor to be able to switch between these two methods:

• Non-Polarized (Liquid Contact) Dermatoscopy: This is the more traditional method. A connection liquid such as ultrasound gel, alcohol, or a special oil is applied between the lens of the device and the skin. This liquid prevents light reflections. This method is excellent for seeing structures in the most superficial layer of the skin (epidermis), for example the fine details of a pigment network.
• Polarized Dermatoscopy: This is a more modern technology. Using special polarized filters, it eliminates surface glare without the need to touch the skin or apply liquid. The greatest advantage of polarized light is that it can penetrate slightly deeper into the skin (the dermis layer). In this way, important clues such as “blue-gray structures” or “shiny white lines,” which may appear in malignant conditions such as melanoma and are located deeper, can be seen.

Modern devices allow the doctor to switch instantly between these two modes with a single button. This is critical for making a complete architectural assessment of both the superficial and deep character of a mole.

Is dermatoscopy really better than examination with the naked eye?

Absolutely yes. Scientific studies have clearly shown that the introduction of dermatoscopy has created a revolution in the diagnosis of skin cancer. This method is not just a “magnifier”; it fundamentally changes the accuracy of diagnosis.

To put it in numbers; dermatoscopy significantly increases the rate of “catching” melanoma, the most dangerous skin cancer (sensitivity), compared to the naked eye.

More importantly, it also increases the “specificity” rate, that is, the rate of correctly identifying a benign mole as “benign.” This means the following: thanks to dermatoscopy, while on the one hand we detect cancers much earlier and with much higher accuracy, on the other hand we also greatly reduce the number of benign moles that would be unnecessarily removed as “suspicious” (and leave unnecessary scars for the patient).

So, can everyone who picks up this device examine moles with the same success?

This is perhaps the most critical point of the subject: No. Dermatoscopy is not only a technology but also a field of expertise. All scientific studies have proven that what increases diagnostic accuracy is not only the device itself, but the main factor is the special dermatoscopy training and experience of the doctor using the device.

During years of training, a dermatologist learns thousands of different mole structures (reticular pattern, globular pattern, starburst pattern, etc.) and which cellular structures they correspond to. This is a “pattern recognition” skill.

While an untrained eye sees only meaningless, chaotic shapes through the dermatoscope, a trained eye can read the “architectural” language of those shapes. Therefore, benefiting from the potential of the device is only possible with the evaluation of a specialist trained in this field.

How does a doctor decide whether a mole is “good” or “bad” when looking at it with dermatoscopy?

This decision is made using a series of systematic evaluation methods, in other words, an “algorithm.” These algorithms help the doctor structure their observations and reach an evidence-based conclusion rather than an emotional one. The most basic approach is the “Two-Step Algorithm.”

First Step: Is the lesion being examined originating from pigment-producing “mole” cells (melanocytic), or is it something else such as “seborrheic keratosis” (age spot), “angioma” (vascular mole), or “basal cell carcinoma”? This first distinction is very important, because sometimes a dangerous melanoma can imitate a benign lesion.

Second Step: If the lesion is decided to be a “mole” (melanocytic), the main question is asked: Is this mole benign, or is it malignant / melanoma?

It is in this second step that more detailed analysis methods come into play.

Is the ABCD rule known among the public also valid in dermatoscopy?

Yes, but it is a much more advanced and detailed version used by dermatologists. This rule is used to score the “irregularity” and “chaos” in a mole.

• A – Asymmetry: How asymmetric are the structure and color of the mole?
• B – Border: How sharply or “blurred” do the borders of the mole end?
• C – Color: How many different colors are there in the mole (such as light brown, dark brown, black, red, blue, white)?
• D – Different Structural Components: How many different architectural structures such as network structures, globules, dots, and lines are present inside the mole?

The key point in this analysis is that asymmetry (A) and multiple colors/structures (C and D) are the most important signs indicating the possibility that a lesion is malignant. The importance of the borders (B) is slightly less than the others, because some benign moles may also have slightly irregular borders.

What is the “Chaos and Clues” method and how is it used in mole examination?

This is a faster and more practical evaluation method that has become very common among experienced dermatologists in recent years.

First, the mole is examined and the question is asked: “Is there chaos in this mole, that is, is there an irregularity, an architectural disorder?” If the mole has a symmetric and orderly structure (there is no chaos), it is most likely benign.

If there is “chaos” (irregularity) in the mole, then the doctor starts looking for “clues” that indicate malignancy. If one or more of these clues are present in a chaotic mole, that mole is considered highly suspicious for melanoma.

Important dermatoscopic clues indicating melanoma are:

• Blue-gray structures (showing that the pigment has gone deeper)
• White shiny lines (visible only with polarized light, showing connective tissue change in deeper layers)
• Irregular black dots or globules
• Asymmetric, finger-like extensions (pseudopods)
• Irregular, thickened, and partially broken pigment network
• Negative pigment network (whitening inside the network)
• Abnormal vascular structures (for example dot-like, comma-shaped, or rod-shaped)

Are there special rules for the palm, sole, or symmetric moles?

Yes, this is a very critical issue. The anatomical region where the mole is located can change all the rules. The most important exception is the “acral” region, that is, the palms of the hands and the soles of the feet.

The skin structure of these regions is different from the skin on our back or arm; it consists of parallel lines (ridges and furrows) like a fingerprint. The evaluation of moles in these regions is subject to a completely different rule.

• Benign Pattern (Parallel Furrow Pattern): In benign moles, the pigment (color) is located in the depressed parts of the skin, that is, in the “furrows.”
• Malignant Pattern (Parallel Ridge Pattern – PRP): In melanoma, on the contrary, the pigment is concentrated on the raised parts of the skin, that is, on the “ridges.”

Seeing the “Parallel Ridge Pattern (PRP)” on the sole of the foot or in the palm is a very strong alarm for melanoma and requires urgent biopsy, even if that lesion appears very small, very symmetric, or very regular in color.

This is one of the most important exceptions to the rule that “symmetric moles are benign.” Although generally regular and symmetric moles are considered benign, some situations are outside this rule.

The situations that must definitely be approached with suspicion even if they appear symmetric are:

• Any mole that newly appears or changes shape in an adult
• A pigmented lesion that forms a noticeable raised bump from the skin (nodular)
• Gray-colored lesions especially located in the face and neck region
• A mole showing a “parallel ridge pattern” on the palm or sole

How do benign moles look under dermatoscopy?

The overwhelming majority of benign moles (nevi) show symmetry and order. One half of the mole resembles the other half, and the color distribution and internal architecture are homogeneous.

The most commonly seen benign patterns are:

• Reticular pattern
• Globular pattern
• Homogeneous (uniform color) pattern
• Cobblestone pattern (generally in congenital moles)
• Starburst pattern (generally in special types of moles called “Spitz” or “Reed” nevus)

What is an “atypical mole” (dysplastic nevus) and why is it confusing?

This is one of the most challenging subjects for both patients and doctors. Atypical moles can be called the “gray zone.” In other words, “they are not malignant but they do not look normal either.”

Under dermatoscopy, they may have a structurally slightly irregular appearance, somewhat blurred borders, and contain more than one shade of brown within them.

Distinguishing an atypical mole from an early-stage melanoma is one of the areas in dermatology that requires the highest level of expertise and experience. The distinguishing factor is that atypical moles generally do not have the specific “high-risk” clues seen in melanoma (for example a prominent blue-gray veil, irregular pseudopods, negative pigment network). However, this distinction is millimetric.

What are the dermatoscopic features of malignant melanoma?

Melanoma is a reflection of uncontrolled cellular proliferation and invasion. What we look for in dermoscopy is this “chaos” and “architectural irregularity.”

The main features of melanoma are:

• Marked structural asymmetry
• Marked color asymmetry
• Irregular, thickened, and partially broken pigment network
• Asymmetric extensions toward the periphery of the mole (pseudopods or streaks)
• Presence of multiple colors (generally more than 3 colors: black, brown, red, blue, white)
• Blue-gray veil (showing depth and pigment in the dermis)
• White shiny lines (showing depth and structural disruption)
• Irregular, atypical vascularity

Why is “mole mapping” (digital dermatoscopy) necessary for people who have many moles?

Some people are in the “high-risk” group. The people accepted as high-risk are:

• Those who have more than 50 moles on their body
• Those who have many “atypical” moles
• Those with a family history of melanoma (in first-degree relatives)
• Those who have had melanoma before

In a patient with this many moles, it is impossible to follow which mole is newly appearing or which one is slightly changing just by relying on memory.

At this point, “Sequential Digital Dermatoscopic Imaging (SDDI),” commonly known among the public as “Mole Mapping,” comes into play. This method is based on taking high-resolution digital dermatoscopic photographs of all moles identified as risky or atypical, together with total body photography, and saving them in special software.

The main purpose of this method is not to create a “mole album” but dynamic biological follow-up. In other words, it uses “time” as a diagnostic tool. At the check-up 6 months or 1 year later, the old and new photographs are superimposed millimetrically.

The benefits of mole mapping are:

• It seriously prevents unnecessary mole removal (biopsy). (Atypical moles that do not change are left in place.)
• It ensures that truly “changing” or “newly appearing” (that is, risky) moles are detected with 100% accuracy.
• It greatly increases the chance of detecting melanomas at the earliest stage (in situ), when they cannot yet harm anyone.
• It reduces the anxiety of the high-risk patient of “what if I miss a mole?”

Which moles are not included in this follow-up and should be removed directly?

Mole mapping and follow-up are not appropriate strategies for every mole. Some lesions have such a fast progression potential or their follow-up is so unreliable that we do not want to take this risk.

Lesions with the following features should be surgically removed directly instead of being included in follow-up (waiting):

• All nodular lesions (forming a noticeable raised bump from the skin)
• Blue or black-blue homogeneous (uniform color) lesions
• Moles showing a prominent regression area (white or gray scar-like areas) inside
• “Spitzoid” lesions known to grow rapidly (especially in adults)
• Lesions that dermatoscopically show “chaos” and strong “clues,” that is, lesions for which the suspicion of melanoma is already high

This strategy (remove the high-risk ones immediately, monitor the suspicious but stable ones) enables the clinician to manage uncertainty in the safest way.

How is a dermatologist’s success measured in mole examination?

This is a quality assurance metric in dermatology. A dermatologist’s success in dermatoscopy and clinical judgment is measured not only by the melanoma detection rate (sensitivity) but also by the rate of avoiding unnecessary surgery (specificity).

This balance is expressed by the “Benign / Malignant (B:M) ratio.” The goal is to remove a certain number of benign moles for every 1 melanoma removed (this ratio is generally targeted between 5 and 10).

If 1 out of every 3 moles removed by a doctor turns out to be melanoma (if the ratio is 2:1), this suggests that the doctor is acting too cautiously and may be missing some early melanomas. If 1 out of every 20 moles removed turns out to be melanoma (if the ratio is 19:1), this shows that the doctor is being overly aggressive and performing unnecessary surgical interventions on patients. The goal is to maintain this healthy balance.

Can artificial intelligence applications replace the doctor in mole examination?

This is a very current and important issue. Mobile phone applications or computer-assisted diagnosis systems are becoming increasingly common. However, with current technology, it is not possible for artificial intelligence (AI) to replace a dermatologist. Artificial intelligence is not a “doctor” but a “tool.”

The important current limitations of artificial intelligence are as follows:

• It does not understand biology or context (the patient’s history); it only matches patterns.
• It may be affected by irrelevant things in the image such as pen marks, rulers, hairs, or air bubbles and make a wrong diagnosis.
• Since most of its training data has been taken from fair-skinned individuals, its performance is low on darker skin tones.
• It generally fails to recognize benign lesions that are very common in the clinic (vascular mole, skin tag, dermatofibroma).
• It may not always show in real-world conditions (different light, different device, different focus) the success it shows in the laboratory.