STUDY

Dermoscopy of Pigmented Seborrheic Keratosis

A Morphological Study
Ralph Peter Braun, MD; Harold S. Rabinovitz, MD; Joachim Krischer, MD; Jürgen Kreusch, MD;
Margaret Oliviero, ARNP; Luigi Naldi, MD; Alfred W. Kopf, MD; Jean H. Saurat, MD

Objectives: To describe morphological features of seb-
orrheic keratosis as seen by dermoscopy and to investi-
gate their prevalence.
Design: Prospective cohort study using macrophotog-
raphy and dermoscopy for the documentation of sebor-
rheic keratosis.
Settings: Seborrheic keratoses were prospectively col-
lected in 2 sites: a private practice in Plantation, Fla (site
1), and the Department of Dermatology at the Univer-
sity Hospital Geneva in Switzerland (site 2).
Patients: A total of 203 pigmented seborrheic kerato-
ses (from 192 patients) with complete documentation
were collected (111 from site 1 and 93 from site 2).
Interventions: Screening for new morphological fea-
tures of seborrheic keratosis and evaluation of all le-
sions for the prevalence of these criteria.
Main Outcome Measures: Identification of new
morphological criteria and evaluation of frequency.
Results: A total of 15 morphological dermoscopic crite-
ria were identified. Standard criteria such as milialike cysts
and comedolike openings were found in a high number of
cases (135 and 144, respectively). We found network and
networklike structures to be present in 94 lesions (46%).
Using standard diagnostic criteria for seborrheic kerato-
sis, 30 lesions would not have been diagnosed as such.
Conclusions: The classic dermoscopic criteria for seb-
orrheic keratosis (milialike cysts and comedolike open-
ings) have a high prevalence but the use of additional der-
moscopic criteria such as fissures, hairpin blood vessels,
sharp demarcation, and moth-eaten borders improves the
diagnostic accuracy. The proper identification of pig-
ment network and networklike structures is important
for the correct diagnosis.
Arch Dermatol. 2002;138:1556-1560

From the Pigmented Skin
Lesion Clinic, Department
of Dermatology, University
Hospital Geneva, Geneva,
Switzerland (Drs Braun,
Krischer, Naldi, and Saurat);
Skin and Cancer Associates,
Plantation, Fla, and
Department of Dermatology,
University of Miami School
of Medicine, Miami, Fla
(Dr Rabinovitz and
Ms Oliviero); and Ronald
O. Perelman Department
of Dermatology, New York
University School of Medicine,
New York (Dr Kopf ).
Dr Kreusch is in private
practice in Lübeck, Germany.
I
N THE PAST 2 decades, there has
been a rising incidence of malig-
nant melanoma.1-6 Due to a lack of
adequate therapies for metastatic
melanoma, the best treatment is
still early diagnosis and prompt surgical
excision of the primary cancer.3 Dermo-
scopy (also known as epiluminescence
microscopy, dermatoscopy, and skin-
surface microscopy) is a simple, noninva-
sive, in vivo method that has been de-
scribed as a useful tool for the early
recognition of malignant melanoma.7-24 The
performance of dermoscopy has been in-
vestigated by many authors. Its use in-
creases diagnostic accuracy 5% to 30% over
clinical visual inspection alone, depend-
ing on the type of skin lesions and experi-
ence of the physician.25,26 According to the
guidelines of the Consensus NetMeeting on
Dermoscopy27 (held in Rome in February
2001; see Web site at http://www
.dermoscopy.org), the diagnostic strategy
includes 2 different levels. In the first level,
one must determine if a lesion is of mela-
nocytic or nonmelanocytic origin. For this
decision, an algorithm using morphologi-
cal key criteria has been proposed. Once the
lesion is identified to be of melanocytic ori-
gin, it must be categorized as benign, sus-
pect, or malignant (second level). To ac-
complish this, 4 different approaches have
been proposed: ABCD rule of dermos-
copy,24,28 Menzies method,17,29,30 7-point
checklist,10 and pattern analysis.19 Diagno-
sis of seborrheic keratosis is, in general, a
clinical diagnosis, but in a certain percent-
age of cases, differential diagnosis be-
tween pigmented seborrheic keratosis and
malignant melanoma is difficult. The most
common dermoscopic characteristics for
seborrheic keratoses are comedolike open-
ings and milialike cysts (Figure 1). Mil-
ialike cysts are round, whitish or yellow-
ish structures that correspond to small
intraepidermal, keratin-filled cysts.17,31-35

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 Frequencies and Distribution of the Criteria Identified
in Step 1 According to Elementary Lesion Type

No. (%) of Lesions

Papule/ Total
Patch Plaque Nodule No.
Face 18 (64) 8 (29) 2 (7) 28
Border
Moth eaten 31 (33) 44 (47) 19 (20) 94
Sharply demarcated 32 (17) 91 (50) 60 (33) 183
Criteria
Hairpin vessels 8 (6) 65 (50) 56 (43) 129
Comedolike openings 13 (9) 79 (55) 52 (36) 144
Fissures 12 (10) 69 (56) 43 (35) 124
Milialike cysts 19 (14) 68 (50) 48 (36) 135
Networklike structures 27 (29) 54 (57) 13 (14) 94
Prominent network 19 (29) 37 (56) 10 (15) 66
Thickened network 11 (19) 38 (66) 9 (16) 58
Heterogenic network 23 (38) 31 (51) 7 (11) 61
Fingerprinting 10 (100) 0 0 10
Blotch 0 12 (75) 4 (25) 16
Crust 0 13 (42) 18 (58) 31
Dots 9 (35) 14 (54) 3 (12) 26
Whitish veil 0 0 3 (100) 3
Exophytic papillary structure 0 12 (75) 4 (25) 16
Colors
Light brown 38 (20) 97 (51) 56 (29) 191
Dark brown 38 (20) 100 (52) 55 (28) 193
Blue gray 12 (11) 55 (51) 41 (38) 108
Yellowish 1 (8) 4 (33) 7 (58) 12
Figure 1. A, Macroscopic photograph of a seborrheic keratosis Maroonish 0 4 (44) 5 (56) 9
(papular/nodular type). B, Dermoscopy shows a sharply demarcated lesion Black 4 (8) 23 (47) 22 (45) 49
with multiple milialike cysts (arrows) and comedolike openings (asterisk).
Total 39 (19) 101 (50) 63 (31) 203

They may also be seen in some congenital nevi and in
some papillomatous melanocytic nevi. Comedolike
openings (pseudofollicular openings, crypts) are
mainly seen in seborrheic keratosis or papillomatous
melanocytic nevi. Keratin-filled invaginations of the
epidermis correspond histopathologically to comedo-
like structures.17,31-35
The purpose of this report was to review dermo-
scopic criteria of pigmented seborrheic keratosis, some
of which have not been clearly defined in the literature.
METHODS
Two sources of clinical cases were used in this study. These
sites were Skin and Cancer Associates, Plantation, Fla (site 1),
and the Pigmented Skin Lesion Clinic, Department of Der-
matology, University Hospital Geneva, Geneva, Switzerland
(site 2).
All pigmented seborrheic keratoses were examined by ex-
perienced “dermoscopists” using a handheld dermoscope (Der-
matoscope [Heine AG], Episcope [Welch-Allyn], or Dermo-
Genius basic [Rodenstock Präzisionsoptik]). All pigmented
seborrheic keratoses data were collected prospectively (3 years
at site 1 and 6 months at site 2). A macroscopic clinical pho-
tograph (Slue imaging system; Canfield Clinical Systems, Fair-
field, NJ) and documentation of the dermoscopic finding (Der-
maphot lens, Heine AG) was performed for every lesion. Since
the diagnosis of pigmented seborrheic keratoses is usually clini-
cal, we considered systematic biopsy (and histopathologic ex-
amination) as unethical, even though this might introduce a
selection bias. Therefore, a biopsy was performed on patient
request or in difficult cases (ie, melanocytic lesion could not
be ruled out with certainty). All slides (clinical and dermo-
scopic), were reviewed by 2 physicians experienced in dermos-
copy (R.P.B. and H.S.R.). During this first evaluation, both au-
thors recorded all morphological findings to define more
precisely the entity of seborrheic keratosis. In the second step,
both authors reevaluated all lesions for presence or absence of
the morphological features previously identified. For the de-
scriptive statistics, the SPSS 9.0 software package (SPSS Inc,
Chicago, Ill) was used.
RESULTS
A total of 203 pigmented seborrheic keratoses were col-
lected (111 lesions from site 1 and 92 lesions from site
2). Histopathologic examination was performed in 99 le-
sions (89/2%) from site 1 and 85 lesions (91%) from site
2. In the first step (examination of both macroscopic and
dermoscopic photographs of all lesions by both investi-
gators), a total of 15 morphological dermoscopic crite-
ria and 6 colors were identified (Table). The elemen-
tary lesion (patch, plaque, and papular/nodular) was
identified on the clinical image. The reticulated type of
seborrheic keratosis was mainly found in patch lesions
and the acanthotic type was mainly found in thicker le-
sions (plaque and papular/nodular).
In the second step, all lesions were evaluated for
the presence of the morphological criteria identified in
the first step. The frequencies of the criteria are shown
in the Table. We found 28 lesions of the face while 175

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 A A
B
∗ ∗
∗ ∗
∗ ∗
∗
∗∗ ∗∗
Figure 2. A, Macroscopic photograph of a seborrheic keratosis
(papular/nodular type). B, Dermoscopy shows a sharply demarcated lesion
with a moth-eaten border (arrows), networklike structures (asterisks),
milialike cysts, and some comedolike openings.
lesions were located elsewhere. Elementary lesions
were distributed as follows: 39 patch lesions (19%), 101
plaque lesions (50%), and 63 papular/nodular lesions
(31%). Hairpin vessels were found in 129 lesions
(63%). They were mainly found in thicker lesions (94%
plaque or papular/nodular lesions). Of the 203 sebor-
rheic keratoses, 183 lesions were sharply demarcated
(90%).
Comedolike openings were found in 144 lesions (71%)
(Figure 1 and Figure 2) and 91% of the lesions with com-
edolike openings were plaque or papular/nodular lesions.
Milialike cysts (Figures 1 and 2) were found in 135 le-
sions (66%) and 86% of them were either plaque or papular/
nodular lesions. The number of milialike cysts ranged from
1 to 184, with a mean of 15 (median, 4).
Lesions were light brown in 191 (94%) and dark brown
in 193 (95%). Blue-gray was present in 108 (53%) lesions
(57% of the lesions from site 1 and 43% from site 2).
Network (Figure 2) was found in 94 lesions (46%):
prominent network in 66 lesions (32%), thickened net-
work in 58 (28%), and heterogenic network in 61 le-
sions (30%). An exophytic papillary structure was found
in 8% of the seborrheic keratoses (75% in plaque and 25%
papular/nodular lesions).36 Fissures (Figure 3) were
found in 124 lesions (61%): 12 (10%) of them were patch
lesions, 69 were plaque lesions (56%), and 43 (35%) were
papular/nodular lesions. A total of 90% of lesions with
fissures were thicker lesions (plaque or papular/nodular).
A moth-eaten border (Figure 2) was found in 94 le-
sions (46%): 31 patch lesions (33%), 44 plaque lesions
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B
Figure 3. A, Macroscopic photograph of a seborrheic keratosis (plaque type).
B, Dermoscopy shows a sharply demarcated lesion with multiple fissures that
give the lesion a brainlike appearance.
(47%), and 19 papular/nodular lesions (20%). By defini-
tion, a “moth-eaten” border is sharply demarcated, but not
all sharply demarcated lesions have a moth-eaten border.
COMMENT
There are many publications on the differential diagno-
sis of pigmented skin lesions. According to the proposal
by the Board of the Consensus NetMeeting on Dermos-
copy, 2 decisions on different levels have to be made: the
first decision (level I) is whether the lesion is of mela-
nocytic or nonmelanocytic origin.27
Once the lesion is identified as melanocytic, it is fur-
ther classified as benign, suspect, or malignant (level II
decision). For seborrheic keratosis, the first level deci-
sion (melanocytic vs nonmelanocytic) is the most im-
portant. If a seborrheic keratosis is considered to be a me-
lanocytic lesion, the lesion might be classified as malignant
in many cases.
One of the key criterion of the algorithm is the pres-
ence of pigment network in the first step of the algo-
rithm. The term “pigment network” corresponds to the
thin, gridlike network consisting of pigmented “lines” and
hypopigmented “holes”31 and should be reserved for me-
lanocytic lesions.17,32-35 The anatomical basis of the latter
is melanin pigment in keratinocytes or in melanocytes along
the dermoepidermal junction. The reticulation (net-
work) represents the rete ridge pattern of the epidermis.
The relatively hypomelanotic holes in the network corre-
spond to tips of the dermal papillae37 and the overlying
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suprapapillary plates of the epidermis.33 In our series, 94
A
lesions (46%) had a network and thus would be classi-
fied as melanocytic lesions in the level I decision, and in
the level II decision (benign vs suspect vs malignant), some
would have been classified as malignant or “suspect.”
By reviewing all seborrheic keratoses where “net-
work” was rated positive, we realized that this structure
did not correspond to the classic “pigment network” of
melanocytic lesions (as described above) but resembled
them. Therefore, we proposed the term “networklike
structures” (Figure 2). The lines of these structures are
often hyperpigmented and may end abruptly at the pe-
riphery. The grids of these “networklike structures” are
much larger than the one seen in a typical pigment net-
work and the holes do not always correspond to the tips B
of the dermal papillae, but to keratin-filled structures (fis-
sures, comedolike openings). We found these network- ∗
like structures in 46% of all lesions in our study. This
high percentage might be because we focused on pig-
mented seborrheic keratosis and therefore might have in-
troduced a selection bias.
Another type of “network” that may be seen in a so-
lar lentigo or an early seborrheic keratosis is “finger-
printing.”38 These are networks that are light brown and
delicate, and have a fingerprint pattern.
Even if one ignores the first step of the algorithm
(evaluation for the presence of pigment network, branched
streaks, or aggregated globules), the second step is also a
Figure 4. A, Macroscopic photograph of a seborrheic keratosis
potential source for misclassification. In the initial algo- (papular/nodular type). B, Dermoscopy shows a sharply demarcated lesion
rithm proposed by Stolz et al,34 the morphological criteria with multiple hairpin blood vessels surrounded by a whitish halo, some
for the identification of seborrheic keratosis (step 2) were milialike cysts (arrows), and comedolike openings (asterisk).
comedolike openings and milialike cysts. A total of 30 le-
sions (15%) did not have either criteria and would not have Fissures are irregular linear, keratin-filled depres-
been identified as seborrheic keratosis. By using the addi- sions that can be seen in seborrheic keratosis. However,
tional criteria presented at the Consensus NetMeeting, mis- they may be seen also in nevi with congenital patterns
classification can be reduced. The use of fissures (brain- and sometimes in common melanocytic nevi. The pres-
like appearance) reduces the number of misclassified cases ence of multiple fissures might give a “brainlike” appear-
to 22 and the additional use of fingerprinting to 14. ance to the lesion (Figure 3).
Apart from the classic criteria, 4 of the 15 morpho- The term “moth-eaten border” (Figure 2) has been
logical criteria for pigmented seborrheic keratosis seemed introduced by Menzies et al17 and according to Schiffner
to be helpful for the diagnosis: fissures, hairpin blood ves- et al38 is also seen in solar lentigines. Since we considered
sels (clustered or grapelike), sharp demarcation, and systematic biopsy of all seborrheic keratoses to be unethi-
moth-eaten border. If these 4 criteria had been added to cal, it was therefore performed on patient request or in cases
the standard criteria, none of the lesions would have been where a doubt concerning the differential diagnosis re-
misclassified. Since we did not test our diagnostic crite- mained (difficult cases). Even though we made this limi-
ria in a set of randomly chosen pigmented skin lesions, tation, histopathological examination was performed in
we are not able to determine the specificity of our crite- more than 90% of the lesions because most of the pa-
ria. If one uses the algorithm for the differential diagno- tients wanted the keratoses to be removed even though
sis of pigmented skin lesions, the use of these additional they were informed about its benign nature (90% of the
criteria reduces the number of lesions that would have lesions that underwent biopsy). Only a minority (10% of
been misclassified and therefore increases the diagnos- the cases) underwent biopsy because of a diagnostic doubt
tic performance of the algorithm. and can therefore be considered as difficult lesions. This
Hairpin blood vessels were found in 129 (63%) of procedure does not really introduce a selection bias be-
the pigmented seborrheic keratoses (Figure 4). Accord- cause all pigmented seborrheic keratoses were included
ing to Kreusch and Koch39 they correspond to long cap- in this study but not all of them underwent biopsy.
illary loops, commonly seen in keratinizing tumors, and We conclude that milialike cysts and comedolike
are mainly found at the border or in the periphery of the openings are excellent diagnostic criteria for the identifi-
lesions. In most of the cases, clusters of blood vessels are cation of the majority of seborrheic keratoses, but that
grouped together and each of them has a whitish halo the use of other criteria (fissures, hairpin blood vessels,
that gives them almost a “grapelike” appearance. This typi- sharp demarcation, and moth-eaten border) decrease the
cal vascular architecture is predominantly seen in seb- risk of misclassification of pigmented seborrheic kerato-
orrheic keratosis. sis and has the potential to improve the diagnostic accu-

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racy of such (especially in difficult cases). Networklike
structures may also be seen in seborrheic keratosis. They
have to be identified as such and should not be confused
with the typical pigment network as seen in melanocytic
lesions. Otherwise, seborrheic keratoses could be mis-
classified as melanocytic lesions.
Accepted for publication February 21, 2002.
We thank David A. Ehrlich for copyreading the
manuscript and his suggestions and comments.
Corresponding author and reprints: Ralph Peter
Braun, MD, Pigmented Skin Lesion Clinic, Department of
Dermatology, University Hospital Geneva, 24, rue Micheli-
du-Crest, CH-1211 Geneva 14, Switzerland (e-mail:
braun@melanoma.ch).
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