Table of Content


Spring 2019, Vol. 27 No. 1

Hong Kong J. Dermatol. Venereol. (2019) 27, 5-11

Original Article

Dermoscopy for pigmented basal cell carcinoma in Asian patients


SH Tay, MMF Chan, CC Oh


Introduction: Basal cell carcinoma (BCC) is the commonest skin cancer worldwide, with the pigmented subtype being more prevalent in Asians. In this case series, we aim to illustrate the value of dermoscopy in distinguishing pigmented BCC among Asians. Materials and methods: Six Chinese patients with six pigmented lesions that were clinically suspicious for pigmented BCC underwent dermoscopic evaluation and results were compared to their histopathological correlates. Results: All six lesions were confirmed to be pigmented nodular BCCs histopathologically. Up-to-date dermoscopic criteria for BCC were identified in all six lesions with shiny white lines, a newly added criterion, detected in four lesions. Conclusions: Dermoscopy is a useful non-invasive bedside tool which helps clinicians to differentiate pigmented BCC from other pigmented lesions. Shiny white lines is a potentially useful addition to the commonly accepted dermoscopic criteria for detecting pigmented BCC in Asians.


Keywords: Asian, basal cell carcinoma, dermoscopy

關鍵詞: 亞洲人、基底細胞癌、皮膚鏡檢查


Basal cell carcinoma (BCC) is the commonest skin cancer worldwide. While metastases are rare, BCCs are known to be locally invasive, aggressive and cause destruction to surrounding structures including bone. Hence, it is imperative to reliably distinguish BCCs from its benign mimickers such that definitive treatment can be offered in good time. Out of the several subtypes of BCC, pigmented BCC is much more prevalent in Asians than Caucasians, accounting for 60% and 75% of BCCs in Hong Kong Chinese and Japanese patients respectively as compared to just 6% of BCCs in Caucasians.1,2 In Singapore, the annual incidence rate of BCCs in the Chinese (Fitzpatrick skin types III to IV) was more than twice of that in the Malays and Indians (Fitzpatrick skin types V to VI), which can be primarily attributed to the increased susceptibility of individuals with fairer complexion to BCC following long-term ultraviolet radiation (UVR) exposure.3

Clinically differentiating between pigmented BCC and benign pigmented skin lesions, especially seborrheic keratosis, can be difficult. Both can appear as well-demarcated, hyperpigmented, "stuck-on" papules or nodules with a smooth to verrucous surface. Moreover, seborrheic keratoses begin to appear during the fourth decade of life and gradually increase in number, which may confound the identification of pigmented BCCs in Asians.3

Complementing the naked eye, dermoscopy is an increasingly essential tool in contemporary dermatological practice, in particular for the diagnosis of BCC with a sensitivity of 98.6% and diagnostic probability of 99%.4-8 In this case series, we aim to illustrate the value of dermoscopy in distinguishing pigmented BCC among Asians.

Materials and methods

Six patients (three Chinese males, three Chinese females) with six pigmented lesions that were clinically suspicious for pigmented BCC underwent dermoscopic evaluation by formally trained dermatologists using commonly accepted and up-to-date criteria as summarised in Table 1.9

Table 1 Dermoscopic criteria of basal cell carcinoma
Vascular Pigment Others
  • Arborising vessels (i.e. branched vessels)
  • Superficial fine telangiectasias (i.e. serpentine vessels)
  • Maple leaf-like areas (i.e. peripheral bulbous extensions with common base)
  • Spoke-wheel areas (i.e. radial lines that converge at central dot or clod)
  • Multiple blue-grey nodules and ovoid nests (i.e. blue-grey clods)
  • In-focus dots
  • Concentric structures
  • Ulceration
  • Multiple small erosions
  • Shiny white-red structureless areas
  • White streaks (i.e. white lines)
Adapted from Wozniak-Rito, A., Zalaudek, I. & Rudnicka, L. Dermoscopy of basal cell carcinoma. Clin Exp Dermatol2018;43:241-7.

Clinical photos of the lesions were taken using the clinicians' cameras and dermoscopic photos were obtained via Dermlite DL 4 (3Gen, San Jose, CA, USA). After dermoscopic evaluation, the clinically suspicious lesions were biopsied and the dermoscopic diagnoses were compared to their histopathological interpretations. Confirmed BCCs were excised with margin clearance. Informed consent was obtained from all patients before enrolment in the study.


The clinical and dermoscopic features of each lesion are listed in Figures 1-6 and Table 2. All six lesions were confirmed via histopathology as pigmented nodular BCCs (Figure 2).

Figure 1 Clinical and dermoscopic features of pigmented lesions. (a) Patient 1; (b) Patient 2; (c) Patient 3; (d) Patient 4; (e) Patient 5; (f) Patient 6.

Table 2 Clinical and dermoscopic evaluation of pigmented lesions
Patient details Location of lesion Clinical features Dermoscopic features
Patient 1 (70-year-old Chinese lady) Inferior to left nostril 6x7 mm ovoid dark brown papule
  1. Arborsing telangiectasia
  2. Large blue-grey ovoid nest
  3. Leaf-like areas
  4. Blue-grey globules
Patient 2 (81-year-old Chinese gentleman) Inferior to right nostril 3x4 mm black papule
  1. Arborsing telangiectasia
  2. Large blue-grey ovoid nest
  3. Shiny white lines
Patient 3 (55-year-old Chinese gentleman) Right cheek 12x10 mm brown-black papule with surface crusts
  1. Arborsing telangiectasia
  2. Large blue-grey ovoid nest
Patient 4 (88-year-old Chinese gentleman) Left to nasal bridge 10x10 mm dark brown-black nodule with central ulceration and rolled-out edges
  1. Arborsing telangiectasia
  2. Large blue-grey ovoid nest
  3. Blue-grey globules
  4. Shiny white lines
  5. Central ulceration
Patient 5 (71-year-old Chinese lady) Left temple 10x12 mm round grey-black nodule with central ulceration
  1. Large blue-grey ovoid nest
  2. Shiny white lines
  3. Central ulceration
Patient 6 (80-year-old Chinese lady) Forehead 8x10 mm ovoid grey-brown nodule with central ulceration and rolled out edges
  1. Large blue-grey ovoid nest
  2. Leaf-like areas
  3. Blue-grey globules
  4. Shiny white lines
  5. Central ulceration

All six lesions possessed large blue-grey ovoid nests while arborising telangiectasia and shiny white lines were each observed in four lesions (Patients 1-4 and Patients 2, 4-6 respectively). Blue-grey globules and central ulceration were each identified in three lesions (Patients 1, 4, 6 and Patients 4-6 respectively) and only two lesions were noted to have leaf-like areas (Patients 1, 6).


This case series demonstrated that dermoscopy is a useful non-invasive bedside tool which helps clinicians to rapidly differentiate pigmented BCC from other pigmented lesions (e.g. seborrheic keratosis, benign melanocytic naevi). In our series, we were able to observe the classic dermoscopic features of pigmented BCC that were in line with those described in current literature and that correlated well with their histopathological characteristics.

Large blue-grey ovoid nests were consistently present in all six lesions whereas vascular structures like arborising telangiectasia were less common. This is in line with the findings of several studies that have reported the lower incidence of vascular structures in pigmented BCCs as compared to their non-pigmented counterparts.5,10 In addition, large blue-grey ovoid nests represent pigmentation in the deeper layers of the dermis, which correspond to the histopathological findings of large well-defined tumour nests with pigment aggregates invading the dermis as seen in Figure 2. Such a finding has been proven to be highly characteristic of pigmented nodular BCCs along with blue-grey nodules.8,11-13

Figure 2 Histopathological features of pigmented lesions (2 patients). Image A was taken from Patient 3 while images B and C were taken from Patient 4. H&E staining at 100x magnification shows nests of basaloid cells with peripheral palisading and focal retraction clefting.

Table 3 Benign mimics of pigmented basal cell carcinoma
Benign mimics
  1. Seborrheic keratosis
  2. Benign melanocytic naevus
  3. Pigmented actinic keratosis/Bowen's disease
  4. Nodular melanoma
Adapted from Bolognia JL, et al. Dermatology Essentials. Philadelphia: Elsevier Saunders, 2014:29.

Shiny white lines refer to the orthogonal short and thick crossing lines seen only with polarised dermoscopy and they may be explained histopathologically as diffuse collagenous stroma and fibrosis in the dermis.14,15 The use of shiny white lines was originally limited to the diagnosis of melanoma as it facilitated the differentiation from naevi and in the identification of more advanced lesions,14 but a 2016 study by Navarette-Dechent et al. suggested the combined presence of shiny white blotches and strands as a additional dermoscopic feature for it has a diagnostic accuracy of 91% for BCCs, albeit for non-pigmented subtypes only.16 Nevertheless, Shitara et al. in another study found no correlation with any specific histopathological subtype of BCC, though shiny white lines were identified in only 30% of BCCs.17 More studies would be needed to evaluate the importance of this dermoscopic feature for the diagnosis of pigmented BCC, which is more prevalent in the Asian context.

Dermoscopy facilitates the visualisation of subsurface skin structures located within the epidermis, dermoepidermal junction, and papillary dermis, which are otherwise not visible to the unaided eye.18 This is achieved by combining increased light penetration into a skin lesion with magnification, and there are currently three types of dermoscopic techniques in use: classic or standard contact, polarised contact and polarised non-contact, all of which in combination permit the physician to assess morphological structures of varying refractive properties. Apart from being lightweight and hence portable, dermoscopy also reduces the number of unnecessary biopsies (i.e. benign-to-malignant excision ratio) by introducing an additional means by which physicians can distinguish between benign and malignant lesions.19,20 Dermoscopy can be significantly operator-dependent leading to the potential for anchoring bias, search satisfaction and incorrect interpretation of findings. However, this can be avoided with formal dermoscopy training .21-23

All in all, dermoscopy is akin to the stethoscope in the dermatology toolbox with unequivocal evidence supporting its use in skin lesion diagnosis, bridging macroscopic clinical dermatology and microscopic histopathology. While initially limited to dermatologists, dermoscopy has steadily gained popularity in other fields of medicine including primary
care.20,24,25 With the increasing incidence and burden of skin cancers reported in Asians and especially so amongst the elderly population,26,27 physicians are encouraged to use dermoscopy to improve their diagnostic accuracy and triage ability for skin cancer. There have been dermoscopic algorithms that offer methodical and disciplined approaches to skin lesions and some have even performed well in a non-expert setting (family care physicians in Australia who had undertaken self-guided formal training).28 In conclusion, our study demonstrates that the role of shiny white lines is an additional dermoscopic feature of pigmented BCC in Asian patients.


All authors have no relevant conflicts of interest to declare.


1. Cheng SY, Luk NM, Chong LY. Special features of non-melanoma skin cancer in Hong Kong Chinese patients: 10-year retrospective study. Hong Kong Med J 2001;7:22-8.

2. Kikuchi A, Shimizu H, Nishikawa T. Clinical histopathological characteristics of basal cell carcinoma in Japanese patients. Arch Dermatol 1996;132:320-4.

3. Tan ES, Ee M, Shen L, Chua H, Chan YH, Tan SH. Basal cell carcinoma in Singapore: a prospective study on epidemiology and clinicopathological characteristics with a secondary comparative analysis between Singaporean Chinese and Caucasian patients. Australas J Dermatol 2015;56:175-9.

4. Menzies SW, Westerhoff K, Rabinovitz H, Kopf AW, McCarthy WH, Katz B. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000;136:1012-6.

5. Altamura D, Menzies SW, Argenziano G, Zalaudek I, Soyer HP, Sera F, et al. Dermatoscopy of basal cell carcinoma: morphologic variability of global and local features and accuracy of diagnosis. J Am Acad Dermatol 2010;62:67-75.

6. Rosendahl C, Tschandl P, Cameron A, Kittler H. Diagnostic accuracy of dermatoscopy for melanocytic and nonmelanocytic pigmented lesions. J Am Acad Dermatol 2011;64:1068-73.

7. Pan Y, Chamberlain AJ, Bailey M, Chong AH, Haskett M, Kelly JW. Dermatoscopy aids in the diagnosis of the solitary red scaly patch or plaque-features distinguishing superficial basal cell carcinoma, intraepidermal carcinoma, and psoriasis. J Am Acad Dermatol 2008;59:268-74.

8. Lallas A, Apalla Z, Argenziano G, Longo C, Moscarella E, Specchio F, et al. The dermatoscopic universe of basal cell carcinoma. Dermatol Pract Concept 2014;4:11-24.

9. Wozniak-Rito A, Zalaudek I, Rudnicka L. Dermoscopy of basal cell carcinoma. Clin Exp Dermatol 2018;43:241-7.

10. Micantonio T, Gulia A, Altobelli E, Di Cesare A, Fidanza R, Riitano A, et al. Vascular patterns in basal cell carcinoma. J Eur Acad Dermatology Venereol 2011;25:358-61.

11. Tabanlioğlu Onan D, Şahin S, Gököz Ö, Erkin G, Çakir B, Elçin G, et al. Correlation between the dermatoscopic and histopathological features of pigmented basal cell carcinoma. J Eur Acad Dermatology Venereol 2010;24:1317-25.

12. Demirtaşoğlu M, Ilknur T, Lebe B, Kuşku E, Akarsu S, Özkan Ş. Evaluation of dermoscopic and histopathologic features and their correlations in pigmented basal cell carcinomas. J Eur Acad Dermatology Venereol 2006;20:916-20.

13. Lallas A, Argenziano G, Kyrgidis A, Apalla Z, Moscarella E, Longo C, et al. Dermoscopy uncovers clinically undetectable pigmentation in basal cell carcinoma. Br J Dermatol 2014;170:192-5.

14. Liebman TN, Rabinovitz HS, Dusza SW, Marghoob AA. White shiny structures: Dermoscopic features revealed under polarized light. J Eur Acad Dermatology Venereol. 2012;26:1493-7.

15. Marghoob AA, Cowell L, Kopf AW, Scope A. Observation of chrysalis structures with polarized dermoscopy. Arch Dermatol 2009;145:618.

16. Navarrete-Dechent C, Bajaj S, Marchetti MA, Rabinovitz H, Dusza SW, Marghoob AA. Association of shiny white blotches and strands with nonpigmented basal cell carcinoma evaluation of an additional dermoscopic diagnostic criterion. JAMA Dermatology 2016;152:546-52.

17. Shitara D, Ishioka P, Alonso-Pinedo Y, Palacios-Bejarano L, Carrera C, Malvehy J, et al. Shiny white streaks: A sign of malignancy at dermoscopy of pigmented skin lesions. Acta Derm Venereol 2014;94:132-7.

18. Marghoob AA, Usatine RP, Jaimes N. Dermoscopy for the family physician. Am Fam Physician 2013;88:441-50.

19. Carli P, De Giorgi V, Crocetti E, Mannone F, Massi D, Chiarugi A, et al. Improvement of malignant/benign ratio in excised melanocytic lesions in the "dermoscopy era": a retrospective study 1997-2001. Br J Dermatol 2004;150:687-92.

20. Menzies SW, Emery J, Staples M, Davies S, McAvoy B, Fletcher J, et al. Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: a sequential intervention trial. Br J Dermatol 2009;161:1270-7.

21. Patel P, Khanna S, McLellan B, Krishnamurthy K. The need for improved dermoscopy training in residency: a survey of US dermatology residents and program directors. Dermatol Pract Concept 2017;7:17-22.

22. Chen YA, Rill J, Seiverling E V. Analysis of dermoscopy teaching modalities in United States dermatology residency programs. Dermatol Pract Concept 2017;7:38-43.

23. Wu TP, Newlove T, Smith L, Vuong CH, Stein JA, Polsky D. The importance of dedicated dermoscopy training during residency: a survey of US dermatology chief residents. J Am Acad Dermatol 2013;68:1000-5.

24. Argenziano G, Puig S, Zalaudek I, Sera F, Corona R, Alsina M, et al. Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol 2006;24:1877-82.

25. Westerhoff K, McCarthy WH, Menzies SW. Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy. Br J Dermatol 2000;143:1016-20.

26. Sng J, Koh D, Siong WC, Choo TB. Skin cancer trends among Asians living in Singapore from 1968 to 2006. J Am Acad Dermatol 2009;61:426-32.

27. Agbai ON, Buster K, Sanchez M, Hernandez C, Kundu R V, Chiu M, et al. Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am Acad Dermatol 2014;70:748-62.

28. Dolianitis C, Kelly J, Wolfe R, Simpson P. Comparative performance of 4 dermoscopic algorithms by nonexperts for the diagnosis of melanocytic lesions. Arch Dermatol 2005;141:1008-14.