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. Author manuscript; available in PMC: 2022 Sep 1.
Published in final edited form as: J Am Acad Dermatol. 2019 Nov 7;85(3):653–664. doi: 10.1016/j.jaad.2019.11.008

Dermoscopic Features of Basal Cell Carcinoma and its Subtypes: A systematic Review

Ofer Reiter 1,2,3, Ilit Mimouni 3, Stephen Dusza 1, Allan C Halpern 1, Yael Anne Leshem 2,3, Ashfaq A Marghoob 1
PMCID: PMC9366765  NIHMSID: NIHMS1823597  PMID: 31706938

Abstract

Background:

Multiple studies have reported on dermoscopic structures in basal cell carcinoma (BCC) and its subtypes, with varying results.

Objective:

To systematically review the prevalence of dermoscopic structures in BCC and its subtypes.

Methods:

Databases and reference lists were searched for relevant trials according to PRISMA guidelines. Studies were assessed for the relative proportion of BCC dermoscopic features. Random effects models were used to estimate summary effect sizes.

Results:

31 studies, consisting of 5,950 BCCs, were included. The most common dermoscopic feature seen in BCC were arborizing vessels (59%), shiny white structures (49%) and large blue-grey ovoid nests (34%). Arborizing vessels, ulceration and blue-grey ovoid nests and globules were most common in nodular BCC; short-fine telangiectasia, multiple small erosions and leaf-like, spoke wheel and concentric structures in superficial BCC; porcelain white areas and arborizing vessels in morpheaform BCC; and arborizing vessels and ulceration in infiltrative BCC.

Limitation:

Studies had significant heterogeneity; studies reporting on BCC histopathologic subtypes did not provide clinical data on pigmentation of lesions.

Conclusion:

In addition to arborizing vessels, shiny white structures are a common feature of BCC. A constellation of dermoscopic feature may aid in differentiating between BCC histopathologic subtypes.

Keywords: Dermoscopy, Dermatoscopy, Basal cell carcinoma, BCC, Nodular basal cell carcinoma, Superficial basal cell carcinoma, infiltrative basal cell carcinoma, morpheaform basal cell carcinoma, pigmented basal cell carcinoma, non-pigmented basal cell carcinoma, large blue-grey ovoid nests, multiple blue-grey dots and globules, multiple in-focus dots, leaf-like areas, spoke wheel areas, concentric structures, arborizing vessels, short-fine telangiectasia, dotted vessels, hairpin vessels, corkscrew vessels, glomerular vessels, polymorphous vessels, shiny white structures, rosettes, shiny white-red structureless background, blue-white veil, ulceration, multiple small erosions

Capsule Summary

The prevalence of dermoscopic features in basal cell carcinoma (BCC) and its subtypes has not been systematically studied.

Even though not as well-known as arborizing vessels, shiny white structures are an important feature of BCC and its subtypes. Different constellations of dermoscopic features aid in the differentiation between BCC subtypes.

Introduction

Basal cell carcinoma (BCC) is the most common human cancer worldwide, and even though it rarely metastasizes, it may cause significant morbidity if left untreated(1). BCC can be either clinically pigmented or non-pigmented, mainly dependent on the patient’s skin type(1). In addition, it has several histopathologic subtypes, with the most common being nodular (nBCC), superficial (sBCC) and morpheaform (mBCC)(2).

Dermoscopy enables the visualization of skin structures that are not visible to the naked eye, through the use of a magnifying lens and polarized and/or non-polarized light. Adoption and use of dermoscopy is increasing with over 90% of dermatologists reporting using this tool in their day-to-day practice in certain countries(3, 4).

Dermoscopy increases sensitivity and specificity for the diagnosis of BCC (5). Multiple studies have previously reported on different structures that are observed under dermoscopy in BCC and its subtypes, with varying results. Based on these studies, dermoscopic structures have been incorporated into several algorithms that assist in the diagnosis of BCC(6, 7).

We present a systematic review summarizing the prevalence of dermoscopic structures observed in BCC and their relative distributions in BCC subtypes.

Methods

A systematic review of the literature was conducted and reported in concordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement(8).

Eligibility criteria

  • Population: Patients with histopathologically proven BCC who underwent dermoscopic examination.

  • Lesion type: Studies that reported on: (1) BCC in general; (2) clinically pigmented and/or non-pigmented BCC; (3) any of the four histopathologic subtypes: nBCC, sBCC, mBCC and infiltrative BCC (iBCC).

  • Study design: All studies including more than four cases of BCC, regardless of design.

Exclusion criteria

  • Studies that limited inclusion of lesions by either a specific anatomic locations (e.g. legs), above a certain diameter, or recurrent /post-biopsy tumors. These studies were excluded because they limit the generalizability of this review.

Outcomes

Primary outcome

Prevalence of dermoscopic structures in BCC

Secondary outcomes

  1. Prevalence of dermoscopic structures in clinically pigmented and non-pigmented BCC

  2. Prevalence of dermoscopic structures in 4 BCC histopathologic subtypes: nBCC, sBCC, mBCC and iBCC.

Literature search

Two reviewers (O.R. and I.M.) searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and the ongoing trials registry of the US National Institutes of Health (www.clinicaltrials.gov) from inception until November 2018. Search terms included “Dermoscopy” or synonyms and basal cell carcinoma or synonyms and known basal cell carcinoma dermoscopic features (e.g. arborizing vessels, shiny white, ovoid nests etc.). MeSH terms were also included, and reference lists were searched. Authors were contacted for missing data and clarifications.

Study selection and data extraction

Two reviewers (O.R. and I.M.) screened the titles and abstracts of all retrieved records. Subsequently, when the title and/or abstract suggested eligibility for the review, the full text article was screened, and relevant data was extracted into an electronic form. Disagreement were resolved by discussion with a third reviewer (Y.A.L).

Risk of bias assessment

Included articles were assessed for risk of bias using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, with a score range of 0–14(9). As performed by us in our previous review(5) and by others(10), we defined a score of 0–6 (<50%) as high risk of bias, 7–10 (50%−75%) as medium risk and 11–14 (>75%) as low risk of bias.

Measures and statistics

Individual studies will be assessed for the outcome the relative proportion of the identified feature within each study. Estimates of relative proportion were made if not explicitly stated within the manuscript if enough information was available to infer the proportion. When the data were unattainable, we attempted to impute the missing responses in accordance with the recommendations put forth in the Cochrane Handbook for Systematic Reviews for Interventions.

Meta-analytic techniques were performed using Stata v14.2 software (StataCorp, College Station, TX, USA) to provide summery prevalence estimates. Random effects models were used to estimate summary effect sizes along with 95% confidence intervals. Separate analyses were performed by BCC subtype. The degree of heterogeneity between studies was assessed by calculating the I2 statistic. Potential reporting bias was assessed by creating funnel plots to visually evaluate any systematic differences between smaller and larger studies and the observed effect sizes.

Results

Our search yielded a total of 1,412 records (Figure I). Thirty-one studies, consisting of 5,950 BCCs, fulfilled the eligibility criteria and were included in the review. Some lesions were reported solely as BCCs without further details and others had additional information, including the histopathological subtype or pigmentation status. Only one study (11)provided data on both the histopathological subtype and the pigmentation status of the lesions, prohibiting analysis of both parameters combined.. Individual studies included different BCC subtypes in their analysis and some included several subtypes of BCC. Out of the 31 studies, 17(11–27) included 1,590 sBCCs, 13(11, 12, 15–25) included 1,503 nBCCs, 7(12, 15, 17–20, 22) included 288 iBCCs and 6(12, 15, 18, 19, 21, 24) included 53 mBCCs. In terms of pigmentation status, 11 studies included 1,253 pigmented BCCs(11, 17, 21, 23, 25, 28–33) and 5 studies included 904 non-pigmented BCCs (11, 23, 28, 30, 34). Characteristics of included studies are detailed in Table I.

Figure I.

Figure I.

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Systematic literature search according to the PRISMA guidelines

Table I.

Characteristics of included studies

Study Country Study design Dermoscope type Polarized/nonpolarized Total number of patients Age (mean or median) Photo or in-person dermoscopy Tumor type Total number of lesions Large blue grey ovoid nests Multiple blue grey dots/globules Multiple in focus blue grey dots/globules Leaf-like areas Spoke Wheel areas Concentric structures Shiny white structures Rosettes Shiny white-red structureless background Ulceration Multiple small erosions Arborizing vessels Short fine telangiectasia Dotted vessels Polymorphous vessels Hairpin vessels Corkscrew vessels Glomerular vessels Blue-white veil
Kreusch 1996 Germany R Ot P BCC 86 77 1 2 9
Argenziano 2004 Italy R Hn P BCC 117 96 6 3 0
Giacomel 2005 Australia Hn 18 65md IP sBCC 24 24 24 17 2 22 1
Demirtasoglu 2006 Turkey Pr MM 30 68md IP pBCC 32 27 20 16 0 20 26 3
Scalvenzi 2008 Italy Pr DL P 42 60md P sBCC 42 2 6 7 0 42 0 33 0 28
Chan 2008 Hong Kong HP Hn 32 77md P pBCC 33 19 22 2 2 25 16
Tabanlioglu Onan 2010 Turkey Pr Hn 29 62mn IP pBCC 40 14 2 11 15 11 11 23
Altamura 2010 Italy & Australia R Ot 609 63md P BCC 609 289 159 31 97 55 46 239 52 348 61 16 86
npBCC 92 0 0 0 0 0 0 45 7 77 13 0
pBCC 517 289 159 31 97 55 46 194 45 271 48 86
Sakakibara 2010 Japan R Hn 49md P pBCC 119 86 4 0 0
Liebman 2011 USA Pr DL P&NP P BCC 149 22 76 20 103 17 42 57 23
Balagula 2011 USA & Switzerland Pr DL P IP BCC 82 39
Micantonio 2011 Italy R Ot 417 64md P BCC 504 306 167 52 41
nBCC 171 152 18 19 15
sBCC 333 154 149 33 26
pBCC 138 63 28 4
npBCC 323 172 139 48
Liebman 2012 USA R DL P P BCC 191 91 27
Trigoni 2012 Greece R DL 96 BCC 132 24 27 6 6 98 39 87 51 43
nBCC 93 3 12 0 0 67 6 72 30 13
sBCC 39 21 15 6 6 31 33 15 21 30
pBCC 96 18 21 6 6 62 27 76 15 36
npBCC 36 6 6 0 0 36 12 11 36 7
Verduzco-Martinez 2013 Mexico R DL 48 70mn P BCC 56 29 20 3 4 4 26 1
nBCC 38 22 15 0 0 2 20 1
pBCC 7 3 2 3 2 0 0 0
sBCC 4 1 0 0 2 0 0 0
iBCC 6 3 2 0 0 2 6 0
Lallas 2013 (1) Italy R DL P&NP 313 67mn P BCC 313 110 100 33 50 32 45 68 148 49 171 81
nBCC 154 77 46 13 13 9 11 17 82 10 114 22
sBCC 77 4 25 10 29 14 21 36 21 31 12 40
mBCC 8 0 0 0 0 0 0 2 7 0 3 3
iBCC 32 8 7 3 1 2 3 7 17 4 19 8
Lallas 2013 (2) Italy R DL 507 66.8mn P BCC 507 184 147 38 70 39 49
nBCC 274 138 75 14 16 11 13
sBCC 113 5 32 13 39 17 22
iBCC 45 10 9 3 1 2 3
mBCC 15 2 2 0 0 0 0
Longo 2014 Italy, Spain, USA & Australia R DL 88 61mn P BCC 88 17 31 21 17 8 7 49 13 21 35 45
nBCC 22 12 9 5 2 2 2 3 6 1 19 4
sBCC 44 4 16 13 14 5 3 30 5 17 5 31
iBCC 22 1 6 3 1 1 2 16 2 3 11 10
Seidenari 2014 Italy R FF NP 335 62mn P BCC 400 119 150 74 30 28 167 119 122 263 198
iBCC 54 19 22 9 2 4 22 33 13 42 24
sBCC 119 11 32 26 13 10 74 13 55 50 86
nBCC 208 87 88 35 12 11 71 66 47 158 75
Zivkovic 2014 Serbia 190 67md P sBCC 87 8 6 7 76 21 28 36 44
nBCC 87 9 9 1 13 55 2 78 8
pBCC 42 28 8 21 7 15 6 25 10
Popadic 2015 (1) Serbia DL 7 69mn IP mBCC 4 0 1 1 0 1 3 0 2 1 3
iBCC 3 1 2 1 0 1 3 1 3 2 0
Popadic 2015 (2) Serbia Pr DL P 116 68md P BCC 151 43 54 35 29 22 78 35 59 53 30 0
nBCC 60 17 20 15 6 8 35 12 19 31 2
sBCC 57 16 24 16 20 12 24 1 35 7 22
Suppa 2015 Italy R Hn P&NP 400 64md P sBCC 335 129 103 60 131 44 42 102 8 109 58 124 129 32 26 6 10 39
nBCC 166 64 39 28 22 1 4 52 2 62 5 130 6 11 10 3 6 34
Emiroglu 2015 Turkey Pr DL P 98 64mn P BCC 98 42 7 9 6 38 42 29 42 15
sBCC 19 0 2 0 0 3 19 0 6
nBCC 37 12 0 1 0 15 9 22 3
pBCC 3 0 3 2 3 0 0 1 0
mBCC 15 9 2 0 0 5 6 6 0
Kim 2015 Korea DL 141 69mn BCC 145 106 86 28 12 23 90 16 77 42 53
Elwan 2015 Egypt DL P 12 IP BCC 12 7 9 4 1 1 9 8 2
nBCC 6 5 5 2 1 0 4 3 1
sBCC 3 1 3 2 0 0 2 2 1
mBCC 1 0 0 0 0 1 1 1 0
Ahnlide 2016 Sweden Pr IP BCC 393 94 125 160 72 282 211
sBCC 70 15 39 14 33 20 54
nBCC 187 54 47 66 20 149 91
iBCC 126 23 37 74 19 109 64
mBCC 10 2 2 6 0 8 2
Navarrete-Dechent 2016 USA R DL P&NP 287 62mn P npBCC 287 110 20
Romano 2016 Argentina R DL P 30 56mn P sBCC 30 4 11 17 5 16 25 6 11 7 22 13 5
Wolner 2018 USA R DL P&NP 348 65mn P BCC 392 96 135 179 79 155 117 262 212 149
pBCC 226 96 135 179 79 76 63 134 129 86
npBCC 166 0 0 0 0 79 54 128 83 63
Papageorgiou 2018 Greece R DL 194 P sBCC 194 32 61 58 (leaf-like+spoke wheel+concentric) 24 56 69 37 146 35 49 19
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BCC – Basal cell carcinoma; DL – DermLite; Hn – Heine; FF – Fotofinder; HP – Historical prospective; iBCC – Infiltrative BCC; IP – In person; mBCC – Morpheaform BCC; MM – Molemax; nBCC – Nodular BCC; npBCC – Non-pigmented BCC; Ot – Other; P – Photo; pBCC – Pigmented BCC; Pr – Prospective; R - Retrospective

Studies described different dermoscopic structures among BCC lesions. These structures can be divided into 3 groups:

  1. Pigmented structures – large blue-grey ovoid nests; multiple blue-grey dots and globules; multiple in-focus dots; leaf-like areas; spoke wheel areas; concentric structures.

  2. Vascular structures – arborizing vessels; short-fine telangiectasia; dotted vessels; hairpin vessels; corkscrew vessels; glomerular vessels; polymorphous vessels.

  3. Non-vascular and non-pigmented structures - shiny white structures. As each study used different terms in this category, we combined the terms shiny white lines, streaks, strands and blotches, crystalline structures and shiny white areas into ‘shiny white structure’; rosettes; shiny white-red structureless background; blue-white veil; ulceration; multiple small erosions.

Most studies used dermoscopic photographs and only 7 studies(13, 15, 18, 24, 29, 31, 35) used in-person dermoscopy. One study(22) used only nonpolarized dermoscopy, 7(14, 15, 21, 24, 26, 35, 36) used polarized dermoscopy and 5(16, 19, 28, 34, 37) used both. The remaining 18 studies did not report on polarization.

Quality assessment

Studies varied in their risk of bias and their QUADAS scores ranged between 0–12. Only one (18) study had a low risk of bias, 9 had a medium risk and 21 of 31 studies had a high risk of bias, mainly due to failure to report whether pathologists, which provided the ‘gold criterion’ diagnosis, were blinded to suspected diagnosis or the dermoscopic description. The QUADAS assessment of participating studies is detailed in Table II.

Table II.

QUADAS criteria(9) for included studies*

Study 1 2 3 4 5 6 7 8 9 10 11 12 12 14 Total
Kreusch 1996 UC UC UC UC UC UC UC UC UC N UC UC N N 0
Argenziano 2004 N Y Y UC Y Y UC Y N UC UC N N N 5
Giacomel 2005 UC N Y UC Y Y UC Y N UC UC Y N N 5
Demirtasoglu 2006 UC N Y UC Y Y UC Y N UC UC Y N N 5
Scalvenzi 2008 Y Y Y UC Y Y UC Y N UC UC Y N N 7
Chan 2008 UC Y Y UC N N UC Y N Y UC UC Y Y 6
Tabanlioglu Onan 2010 Y Y Y UC Y Y UC Y N UC UC Y N Y 8
Altamura 2010 UC N Y UC Y Y UC UC N UC UC N N N 3
Sakakibara 2010 UC N Y UC Y Y UC N N UC UC UC N N 3
Liebman 2011 Y N Y UC Y Y UC Y N UC UC UC N Y 6
Balagula 2011 Y N Y UC Y Y UC N N Y UC Y N N 6
Micantonio 2011 Y Y Y UC Y Y UC N N UC UC UC N N 5
Liebman 2012 UC UC Y UC Y Y UC Y N UC UC N N Y 5
Trigoni 2012 UC N Y UC UC UC UC Y N UC UC UC N N 2
Verduzco-Martinez 2013 UC Y Y UC Y Y Y Y Y Y Y N N N 9
Lallas 2013 (1) UC Y Y UC Y Y UC Y Y UC UC UC Y Y 8
Lallas 2013 (2) UC Y Y UC Y Y UC Y N N UC N Y N 6
Longo 2014 UC Y Y UC Y Y UC Y N UC UC N N N 5
Seidenari 2014 UC N Y Y Y Y UC Y N Y UC N N N 6
Zivkovic 2014 UC UC Y UC Y Y UC Y N UC UC UC N N 4
Popadic 2015 (1) UC UC Y UC Y Y UC Y N N UC Y N N 5
Popadic 2015 (2) Y Y Y UC Y Y UC Y Y UC UC Y N N 8
Suppa 2015 Y UC Y UC Y Y UC Y N UC UC UC N N 5
Emiroglu 2015 UC N Y UC Y Y UC Y N UC UC UC N N 4
Kim 2015 UC Y Y UC Y Y UC Y Y UC UC UC Y Y 8
Elwan 2015 UC Y Y Y Y Y UC Y N Y UC Y Y N 9
Ahnlide 2016 Y Y Y Y Y Y UC Y Y Y UC Y Y Y 12
Navarrete-Dechent 2016 Y Y Y UC Y Y UC Y N Y UC N N Y 8
Romano 2016 UC UC Y UC Y Y UC UC UC UC UC UC Y Y 5
Wolner 2018 Y Y Y UC Y Y UC Y N UC UC UC Y Y 8
Papageorgiou 2018 UC Y Y UC Y Y UC Y N Y UC N N N 6
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N – No; UC – unclear; Y – Yes

1.

Was spectrum of patients representative of patients who will receive the test in practice?

2.

Were selection criteria clearly described?

3.

Is the reference standard likely to correctly classify the target condition?

4.

Is the time period between the reference standard and index test short enough to be reasonably sure the target did not change between tests?

5.

Did the whole sample or a random selection of the sample receive verification using a reference standard of diagnosis?

6.

Did patients receive the same reference standard regardless of the index test result?

7.

Was the reference standard independent of the index test?

8.

Was the execution of the index test described in sufficient detail to permit replication?

9.

Was the execution of the reference standard described in sufficient detail to permit replication?

10.

Were the index test results interpreted without knowledge of the results of the reference standard?

11.

Were the reference standard results interpreted without knowledge of the results of the index test?

12.

Were the same clinical data available when the test results were interpreted as would be available in practice?

13.

Were uninterpretable/intermediate test results reported?

14.

Were withdrawals from the study explained?

Primary outcome - Prevalence of dermoscopic structures in BCC

The prevalence of different dermoscopic features among BCC and its subtypes is detailed in Table III. Looking at BCCs in general, the most common dermoscopic feature was arborizing vessels, with a pooled prevalence of 59% (95% CI 53%−65%). However, it was not the only vascular structure that was reported. Other vascular structures included: short-fine telangiectasia, dotted vessels, polymorphous vessels, hairpin vessels, corkscrew vessels and glomerular vessels with varying prevalence (see Table III).

Table III.

Dermoscopic features prevalence among BCC and its subtypes

Feature BCC   Nodular BCC Superficial BCC Infiltrative BCC Morpheaform BCC   Non-pigmented BCC Pigmented BCC
N ES N ES N ES N ES N ES N ES N ES
Pigmented structures Large blue-grey ovoid nests 14 0.34 (0.27, 0.42) 12 0.36 (0.25, 0.47) 15 0.14 (0.07, 0.23) 7 0.21 (0.13, 0.31) 6 0.13 (0.0, 0.39) 3 0.02 (0.0, 0.12) 9 0.48 (0.35, 0.61)
Multiple blue-grey dots and globules 13 0.34 (0.28, 0.41) 11 0.26 (0.17, 0.35) 14 0.27 (0.21, 0.34) 6 0.28 (0.18, 0.39) 5 0.05 (0.0, 0.19) 3 0.02 (0.0, 0.12) 9 0.38 (0.23, 0.55)
Multiple in focus blue-grey dots and globules 6 0.17 (0.06, 0.32) 5 0.13 (0.07, 0.22) 5 0.18 (0.13, 0.25) 4 0.07 (0.02, 0.14) 3 0.01 (0.0, 0.16) 2 0.0 (0.00, 0.01) 2 0.23 (0.20, 0.27)
Leaf-like areas 13 0.15 (0.12, 0.18) 11 0.06 (0.02, 0.10) 14 0.25 (0.18, 0.33) 6 0.04 (0.0, 0.10) 5 0.0 (0.0, 0.01) 3 0.0 (0.0, 0.0) 9 0.27 (0.16, 0.39)
Spoke wheel areas 11 0.08 (0.07, 0.09) 10 0.03 (0.01, 0.05) 11 0.10 (0.06, 0.15) 6 0.02 (0.0, 0.06) 5 0.0 (0.0, 0.03) 2 0.0 (0.0, 0.01) 7 0.13, (0.04, 0.25)
Concentric structures 6 0.10 (0.07, 0.13) 5 0.05 (0.03, 0.07) 6 0.14 (0.09, 0.20) 4 0.08 (0.04, 0.13) 2 0.0 (0.0, 0.08) 1 0.0 (0.00, 0.04) 1 0.09 (0.07, 0.12)
Vascular structures Arborizing vessels 16 0.59 (0.53, 0.65) 12 0.75 (0.69, 0.82) 16 0.21 (0.13, 0.30) 6 0.76 (0.59, 0.90) 5 0.51 (0.26, 0.77) 4 0.63 (0.43, 0.81) 11 0.55 (0.45, 0.65)
Short fine telangiectasias 12 0.32 (0.22, 0.43) 10 0.17 (0.08, 0.28) 14 0.60 (0.51, 0.69) 5 0.40 (0.27, 0.53) 4 0.24 (0.0, 0.61) 4 0.55 (0.27, 0.81) 6 0.20 (0.05, 0.42)
Dotted vessels 1 0.01 (0.00, 0.06) 0 -- 1 0.18 (0.13, 0.34) 0 -- 0 -- 0 -- 0 --
Polymorphous vessels 3 0.12 (0.00, 0.42) 1 0.07 (0.03, 0.12) 1 0.10 (0.07, 0.13) 0 -- 0 -- 1 0.38 (0.31, 0.46) 2 0.23 (0.19, 0.28)
Hairpin vessels 4 0.06 (0.02, 0.12) 2 0.08 (0.06, 0.12) 5 0.16 (0.07, 0.26) 0 -- 0 -- 1 0.15 (0.11, 0.19) 2 0.01 (0.0, 0.03)
Corkscrew vessels 1 0.33 (0.25, 0.41) 2 0.05 (0.03, 0.08) 2 0.05 (0.03, 0.07) 0 -- 0 -- 1 0.19 (0.08, 0.36) 1 0.38 (0.28, 0.48)
Glomerular vessels 2 0.06 (0.04, 0.08) 2 0.06 (0.04, 0.09) 4 0.07 (0.03, 0.13) 0 -- 0 -- 0 -- 1 0.0 (0.0, 0.03)
Other Shiny white structures 6 0.49 (0.40, 0.58) 3 0.43 (0.26, 0.61) 6 0.43 (0.22, 0.66) 1 1.0 (0.29, 1.00) 2 0.41 (0.18, 0.66) 2 0.42 (0.37, 0.46) 2 0.31 (0.24, 0.38)
Rosettes 2 0.13 (0.10, 0.17) 1 0.01 (0.0, 0.04) 1 0.02 (0.01, 0.05) 0 -- 0 -- 1 0.07 (0.04, 0.11) 0 --
Shiny white-red structureless areas 7 0.40 (0.28, 0.54) 8 0.24 (0.12, 0.39) 11 0.79 (0.64, 0.91) 4 0.39 (0.23, 0.57) 4 0.29 (0.12, 0.50) 1 1.00 (0.90, 1.00) 3 0.28 (0.0, 0.74)
ulceration 11 0.08 (0.07, 0.09) 10 0.31 (0.20, 0.44) 14 0.23 (0.13, 0.35) 6 0.44 (0.26, 0.62) 4 0.58 (0.09, 0.99) 3 0.38 (0.27, 0.50) 8 0.37 (0.28, 0.48)
multiple small erosions 7 0.20 (0.12, 0.29) 7 0.10 (0.04, 0.18) 10 0.43 (0.31, 0.54) 5 0.19 (0.08, 0.32) 3 0.06 (0.0, 0.38) 1 0.08 (0.03, 0.15) 2 0.09 (0.06, 0.11)
Blue-white veil 5 0.10 (0.01, 0.26) 3 0.11 (0.0, 0.29) 3 0.06 (0.03, 0.10) 1 0.0 (0.0, 0.46) 1 0.0 (0.0, 0.98) 0 0.0 (0.0, 0.04) 4 0.19 (0.03, 0.42)
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N – Number of studies; ES – Effect size

The second most common feature was shiny white structures (49%; 95% CI 40%−58%) followed by shiny white-red structureless areas (40%, 95% CI 28%−54%).

The third most common category was pigmented structures, including large blue-grey ovoid nests (34%, 95 CI 27%−42%) and multiple blue-grey dots and globules (34%, 95% CI 28%−41%).

1. Clinically pigmented and non-pigmented BCC

Both pigmented and non-pigmented BCC commonly presented with arborizing vessels (63%, 95% CI 43%−81% and 55%, 95% CI 45%−65%, respectively). However, while pigmented BCC presented pigmented structures with frequencies of up to 48%, non-pigmented BCC presented these structures in only 0–2% of lesions. On the other hand, non-pigmented BCC more commonly presented with vascular structures other than arborizing vessels.

BCC histopathologic subtypes
Nodular BCC

nBCC most commonly presented with arborizing vessels (75%, 95% CI 69%−82%), shiny white structures (43%, CI 26%−61%) and ulceration (31%, 95% CI 20%−44%). When pigmentation was present, the most common structure was large blue-grey ovoid nests (36%, 95% CI 25%−47%). nBCC very seldomly presented with leaf-like areas (6%, 95% CI 2%−10%), spoke wheel structures (3%, 95% CI 1%−5%) or concentric structures (5%, 95% CI 3%−7%).

Superficial BCC

The most common dermoscopic structures described in sBCC were short-fine telangiectasia (60%, 95% CI 51%−69%), multiple small erosions (43%, 95% CI 31%−54%) and shiny white structures (43%, 95% CI 22%−66%). In addition, 79% of lesions presented with shiny white-red structureless background (95% CI 64%−94%). When pigmentation was present, it most commonly presented as multiple blue-grey dots and globules (27%, 95% CI 21%−34%) and leaf-like areas (25% 95% CI 18%−33%).

Morpheaform BCC

Only 53 cases of mBCC were included in this review. One study found that 75% of mBCC showed structureless hypopigmentation (porcelain white areas)(38). Another common dermoscopic feature among mBCC was arborizing vessels (51%, 95% CI 26%−77%) and many of these tumors were ulcerated (58%, 95% CI 9%−99%). When pigmentation was present, it was most commonly large blue-grey ovoid nests (13%, 95% CI 0%−36%), however, in general mBCC rarely presented with pigmentation dermoscopically (average of 0–13% of lesions).

Infiltrative BCC

The majority of iBCC presented with arborizing vessels (76%, 95% CI 59%−77%), followed by ulceration (44%, 95% CI 26%−62%) and short-fine telangiectasia (40%, 95% CI 27%−53%). iBCC rarely presented with leaf-like areas (4% 95% CI 0–10%).

Dermoscopic structures distribution between different BCC histopathologic subtypes

No single dermoscopic structure was found to be unique for a specific histopathologic subtype. Nevertheless, some structures had different prevalence among different subtypes.

Pigmented structures –

Leaf-like and spoke wheel areas were more common in sBCC compared to all other subtypes Large blue-grey ovoid nests were more common in nBCC compared to sBCC.

Vascular structures –

Arborizing vessels were more common in nBCC and iBCC compared to sBCC. Short-fine telangiectasia were more common in sBCC compared to nBCC.

Non-vascular and non-pigmented structures –

Shiny white structures were common among all BCC subtypes (41%−100%) but were not found to have different prevalence among different subtypes. Multiple small erosions were more common among sBCC compared to nBCC. The prevalence of ulcers, however, was not different among different subtypes.

Discussion

The aims of this paper were to systematically review the evidence for the prevalence of dermoscopic structures among BCC and its clinical (pigmented vs non-pigmented) and histopathologic subtypes and to investigate whether these structures can differentiate between the subtypes.

There was not a single dermoscopic structure that appeared in all BCC lesions, nor was there a structure exclusive for a specific BCC subtype. It seems that the most prominent features for the diagnosis of BCC are blood vessels, specifically arborizing vessels or short fine telangiectasia, identified in 51%−75% of the tumors, depending on BCC subtype. The second important clue for the diagnosis of BCC is shiny white structures, that appeared in 41%−49% of tumors. Pigmented structures were only reported in up to 36% of cases of BCCs and its histopathological subtypes.

Pigmented structures appeared almost exclusively in pigmented lesions. Pigmented structures may be more easily identifiable than other BCC features (e.g. shiny white structures), which could explain why dermoscopy has a higher diagnostic accuracy for pigmented BCC versus non-pigmented BCC(5). The frequency of non-pigmented structures such as vascular structures was lower in pigmented versus non-pigmented BCC, probably due to obscureness of these structures by pigment in the former. As data on the histopathologic subtypes of pigmentary vs non-pigmentary BCC was not provided, we could not correlate the dermoscopic findings with the histopathological ones for these subgroups.

In analyzing histopathologic BCC subtypes, we found that even though they had different frequencies of dermoscopic structures, most could not clearly differentiate between the subtypes. For example, 43% of nBCCs presented shiny white structures, but the same frequency was observed in sBCCs. The only two dermoscopic structures that were relatively unique for one subtype were leaf-like areas and shiny white-red structureless background in sBCC.

Interestingly, “classic” nBCC features, such as large blue-grey ovoid nests that correlate with large tumor nests in the dermis(39), were also present in sBCCs and “classic” sBCC features, such as leaf-like areas that correlate with small basaloid cells nests in the dermo-epidermal junction(39), were present in nBCCs. This may at least partly be explained by variations in histopathologic analysis. Depending on the different sectioning and readers, the same lesion can be classified as superficial, nodular or mixed type BCC.

The two most commonly observed vascular structures were arborizing vessels, more typical for nBCC and iBCC, and short-fine telangiectasia that were more characteristic of sBCC. Nonetheless, all BCC subtypes displayed a variety of vessel morphologies, including ones not usually associated with BCC. The significance of this finding is that vessels should be interpreted in the context of the clinical and dermoscopic findings. For example, if a lesion displays glomerular vessels but also other findings consistent with BCC, expand your differential beyond Bowen’s disease, as 6% of BCCs in this review displayed glomerular vessels. Another example of a feature that is classically associated with lesions other than BCCs is the blue-white veil, which was reported in 10% of BCCs lesions included in this review.

The main limitation of this review is the significant heterogeneity among the studies, which also prevented conducting a meta-analysis. One of the reasons for the heterogeneity is that dermoscopic criteria for BCC are still evolving and studies from different time points reported on different criteria and used different terms. Another reason can be attributed to the fact that studies used different light polarization mode, which is critical in evaluating the prevalence of dermoscopic features. Some dermoscopic features, such as shiny white structures, are only seen under polarized light, and some are seen better under non-polarized light. In addition, non-polarized dermoscopy is most-likely done with direct contact between the dermoscope and the skin, which may hamper the visualization of blood vessels as they as blanched due to the pressure of the lens(40).

Additional limitations include the medium to high risk of bias of most studies and that, except for one study(11), all studies that reported on histopathologic subtypes did not provide clinical data on pigmentation of lesions. It is to be expected that the prevalence of pigmented structures was directly impacted by the frequency of clinically pigmented lesions in these studies. Lacking this data, we cannot reach conclusions on the relative significance of pigmented structures in diagnosing the different BCC histopathologic subtypes.

In conclusion, it comes as no surprise that arborizing blood vessels, which are the most well-known characteristic of BCC, are also its most common dermoscopic feature. However, shiny white structures, which are not as well-known, were found to be the second most common feature of BCC. Frequencies of dermoscopic features differ between BCC histopathologic subtypes and the constellation of features may aid in the diagnosis: nBCC is associated with arborizing vessels, ulceration and blue-grey ovoid nests and globules; sBCC is associated with short-fine telangiectasia, multiple small erosions and leaf-like, spoke wheel and concentric structures; mBCC is associated with porcelain white areas and arborizing vessels; and iBCC is associated with arborizing vessels and ulceration. The paucity of dermoscopic findings in the latter subtypes may contribute to difficulty in making these diagnoses. Further studies are required to differentiate dermoscopic findings in pigmented and in non-pigmented BCC histopathologic subtypes.

Funding sources:

None

Footnotes

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Conflicts of interest: none

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