Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society

Background: Dermoscopy can assist clinicians in the evaluation and diagnosis of skin tumors. Since dermoscopy is becoming widely accepted and used in the medical community, there is now the need for a standardized method for documenting dermoscopic findings so as to be able to effectively communicate such information among colleagues. Objectives: Toward this end, the International Dermoscopy Society embarked on creating a consensus document for the standardization and recommended criteria necessary to be able to effectively convey dermoscopic findings to consulting physicians and colleagues. Methods: The Dermoscopy Report Steering Committee created an extensive list of dermoscopic criteria obtained from an exhaustive search of the literature. A preliminary document listing all the dermoscopic criteria that could potentially be included in a standardized dermoscopy report was elaborated and presented to the members of the International Dermoscopy Society Board in two meetings of the Society and subsequently discussed via Internet communications between members and the Steering Committee. Results: A consensus document including 10 points categorized as either recommended or optional and a template of the dermoscopy report were obtained. The final items included in the document are as follows: (1) patient's age, relevant history pertaining to the lesion, pertinent personal and family history (recommended); (2) clinical description of the lesion (recommended); (3) the two-step method of dermoscopy differentiating melanocytic from nonmelanocytic tumors (recommended); (4) the use of standardized terms to describe structures as defined by the Dermoscopy Consensus Report published in 2003. For new terms it would be helpful to provide a working definition (recommended); (5) the dermoscopic algorithm used should be mentioned (optional); (6) information on the imaging equipment and magnification (recommended); (7) clinical and dermoscopic images of the tumor (recommended); (8) a diagnosis or differential diagnosis (recommended); (9) decision concerning the management (recommended); (10) specific comments for the pathologist when excision and histopathologic examination are recommended (optional). Limitations: The limitations of this study are those that are intrinsic of a consensus document obtained from critical review of the literature and discussion by opinion leaders in the field. Conclusions: Although it may be acceptable for a consulting physician to only state the dermoscopic diagnosis, the proposed standardized reporting system, if accepted and utilized, will make it easier for consultants to communicate with each other more effectively.