Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 1 International Dermoscopy Society (IDS) Criteria for Skin Tumors: Validation for Skin of Color Through a Delphi Expert Consensus by the “Imaging in Skin of Color” IDS Task Force Balachandra S Ankad1, Biswanath Behera2, Aimilios Lallas3, Bengu Nisa Akay4, Yasmeen J Bhat 5, Payal Chauhan6, Nkechi Anne Enechukwu7, Shamir Geller8, Abhijeet Kumar Jha9, Feroze Kaliyadan10, Kayitesi Kayitenkore11, Awatef Kelati12, Keshavamurthy Vinay13, Jennifer Stein14, Ibrahima Traoré15, Richard P Usatine16, Enzo Errichetti17 1 Department of Dermatology, Venereology and Leprosy, SN Medical College, Bagalkot, Karna-taka, India 2 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, India 3 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece 4 Department of Dermatology, School of Medicine, Ankara University, Ankara, Turkey; 5 Department of Dermatology, Venereology and Leprology, Government Medical College, University of Kashmir, Srinagar, Jammu and Kashmir, India 6 Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Bilaspur, Himachal Pradesh, India 7 Nnamdi Azikiwe University/Nnamdi Azikiwe Teaching Hospital Nnewi, Anambra State, Nigeria; 8 Division of Dermatology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 9 Department of Dermatology & STD, Patna Medical College & Hospital, Patna, India 10 Department of Dermatology, Sree Narayana Institute of Medical Sciences, Ernakulum, India 11 University of Rwanda, Kigali, Rwanda 12 Dermatology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco 13 Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India 14 The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA 15 Dermatological clinic, Conakry, Guinea 16 Department of Dermatology and Cutaneous Surgery, Department of Family and Community Medicine, University of Texas Health San Antonio, San Antonio, TX, USA 17 Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Udine, Italy Key words: dermoscopy, neoplasias, neoplastic dermatoses, skin of color, tumors Citation: Ankad BS, Behera B, Lallas A, et al. International Dermoscopy Society (IDS) criteria for skin tumors: validation for skin of color through a Delphi expert consensus by the “Imaging in Skin of Color” IDS Task Force. Dermatol Pract Concept. 2023;13(1):e2023067. DOI: https://doi.org/10.5826/dpc.1301a67 Accepted: November 17, 2022; Published: January 2023 Copyright: ©2023 Ankad et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Enzo Errichetti, Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Piazzale Santa Maria della Misericordia, 15. 33100-Udine, Italy. Tel: (+39) 0432559822. E-mail: enzoerri@yahoo.it 2 Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 Introduction Dermoscopy has nowadays become an invaluable tool for the dermatologist’s daily practice as it allows to high- light relevant findings corresponding to key histological changes that are not visible to the naked eye, thus increas- ing diagnostic accuracy in the field of both neoplastic and non-neoplastic skin conditions [1,2]. Importantly, to make dermoscopic examination as reproducible as possible it is of utmost importance to follow a systematic analytical approach, with a standardized set of parameters to evalu- ate and a uniform terminology to use [3-5]. However, over time, many authors employed an arbitrary approach with the use of different terms, even to refer to the same dermo- scopic finding, with a consequent heterogeneous semeiol- ogy generating confusion among users [4]. In order to face such an issue, the International Dermoscopy Society (IDS) has released two consensus documents encompassing ba- sic dermoscopic variables to assess with the corresponding vocabulary to adopt, one for skin neoplasms and one for non-neoplastic dermatoses (inflammatory, infectious, and infiltrative diseases) [4,5]. Notably, these guidelines were issued considering the literature evidence on light photo- types, with consequent possible limitations if used in dark skin [4,5]. Indeed, it has been shown that dermoscopic patterns of skin disorders may remarkably vary (espe- cially for phototypes V/VI) because of the different color backgrounds as well as specific reaction patterns typical of darker phototypes (e.g., lability of pigment and greater tendency to follicular or sclerotic reactions) [6,7]. For these reasons, the IDS supported a validation process of its con- sensus document on non-neoplastic dermatoses for use in dark skin, yet such a procedure has not been performed with regard to neoplastic disorders [8]. This document was promoted by the “Imaging in Skin of Color” IDS Task Force with the aim of validating the dermoscopic criteria/terminology provided by the IDS for skin tumors for the use in skin of color by a consensus process involving a panel of experts routinely dealing with dark-skinned patients (phototypes IV, V, and VI). Materials and Methods The consensus was performed according to the two-round “Delphi method”, with an iterative process including two rounds of email questionnaires starting from a list of pre- selected items (i.e., dermoscopic criteria provided by the IDS)  [5]. Notably, differently from the “modified Delphi method”, the Delphi process makes it possible to gain expert consensus on variable issues by using at least two rounds of questionnaires and involving at least 5-10 participants, without the need for an in-person discussion [9-11]. So, similarly to the validation process for skin of color carried out for non-neoplastic dermatoses [8], we chose to avoid a face-to-face meeting in order to reduce decisional biases be- cause of group interaction [9-11]. Introduction: A structured set of eight basic dermoscopic parameters (lines, clods, dots, circles, pseu- dopods, structureless, else, and vessels) including a total of 77 variables with corresponding descrip- tive and metaphoric vocabulary has been released for evaluation of skin tumors by the International Dermoscopy Society (IDS). Objectives: To validate the aforementioned criteria for the use in darker phototypes (phototypes IV-VI) via an expert consensus. Methods: The two-round “Delphi method” was adopted, with an iterative process including two rounds of email questionnaires. Potential panelists were asked to take part in the procedure via email on the basis of their expertise in the dermoscopy of skin tumors in dark phototypes. Results: A total of 17 participants were involved. All the original variables of the eight basic parameters reached agreement during the first round, except for “pink small clods” (“milky red globules”) and “structureless pink zone” (“milky red areas”). Moreover, during the first round, panelists proposed a change of three existing items and the introduction of four new items, i.e., “black, small clods” (“black globules”), “follicular plugs”, “erosions/ulcerations”, and “white color around vessels” (“perivascular white halo”). All such proposals achieved agreement, thus being included in the final list, for a total of 79 items. There was consistency between the descriptive and metaphoric approaches in terms of scoring. Conclusions: Albeit most of the original items were considered applicable even for skin of color, there are some points of differences that physicians need to know. No significant preference was found between descriptive and metaphoric terminology among panelists. ABSTRACT Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 3 Panel Selection Panel selection was performed by sending an e-mail in- vitation from the coordinators of the process (E.E. and B.S.A.) to experts in the field of dermoscopy in skin of color (phototypes IV, V, and VI) across the world. In de- tail, all the members of the “Imaging in Skin of Color” IDS Task Force were invited to join the panel, along with researchers who had published at least five peer-reviewed articles or book chapters on such a topic as either the first or last author. In total, 22 international experts were in- vited as panel members; participants’ assessments were blinded and anonymity was maintained during the entire process of consensus. Round 1 The dermoscopic criteria provided by the IDS [5] were tab- ulated (Table 1) and shared with all the panelists via emails, including eight basic dermoscopic parameters with a total of 77 items. As per the original consensus, descriptive termi- nology and corresponding metaphoric vocabulary for each dermoscopic parameter were included in the validation pro- cess. Instructions and aims of the consensus process were also circulated. Panelists were asked to judge on a 5-point scale the level of agreement on the relevance of each variable (descriptive and metaphoric) for the use in dark-skinned patients (1, no agreement; 2, low agreement; 3, moderate agreement; 4, agreement; and 5, strong agreement). In case of disagreement/ poor agreement (score 1-3) on any of the items, participants were invited to justify their choice and provide (optional) suggestions to improve them. Experts were also given the chance to propose additional variables not included in the original list. Each item was considered appropriate for the use in skin of color in case of achievement of a score of 4 or 5 out of 5 by more than 80% of the experts. The agreement threshold of 80% was selected based on the literature guid- ance on Delphi consensus [10]. Parameters which had not attained 80% agreement would be modified in accordance with suggestions (if any) given by the participants and re- distributed, along with new possible proposed items, to the panel of experts for round 2. Round 2 In round 2, panelists were asked to assess the modified and new parameters (if any) resulting from round 1, following the same methodology as the previous round. At the end of round 2, a comparison between the rating of descriptive and metaphoric terminology for each of the eight basic dermo- scopic parameters was carried out. Data were expressed as means ± SD and analysis was performed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA, USA) by the unpaired, two-tailed student’s t-test, with p-value of <0.05 deemed statistically significant. Results A total of 17 participants were involved in both rounds of the consensus. With regard to descriptive terminology, all the items received agreement in round 1 except for “pink small clods” and “structureless pink zone”, which reached a mean score of 3.94 and 3.95, respectively. Similarly, corresponding metaphoric terms for such variables (i.e., “milky red globules” and “milky red areas”) did not achieve agreement too, with a mean score of 3.98 and 3.86, respectively. Four new items were proposed during the first round, i.e., (I) “black, small clods” (black globules) for parameter 2 (“CLODS”); (II) follicular plugs and (III) erosions/ulcerations for parameter 7 (“ELSE”); and (IV) white color around vessels (perivascular white halo) for parameter 8 (“VESSELS”). Moreover, the group of experts suggested changing three items when it comes to descriptive terminology, including (I) “clods, brown or blue, concentric (clod within a clod)” to “clods, brown, blue or black, con- centric (clod within a clod)”; (II) “dots, gray” to “dots, gray, blue or black”; and (III) “dots, gray and circles, gray” to “dots, gray, blue or black and circles, gray, blue or black”. All such proposals were rated during the second round and achieved agreement, thus being included in the final list. Therefore, at the end of the validation process, a total of 79 items were identified (72 out of the 77 proposed by the IDS plus seven added in the course of the consensus procedure). Table 1 displays details on agreement rates and mean scores for rounds 1 and 2. Figures 1-4 depict schematic illustrations of the new/changed items and examples of skin tumors typi- fied by such structures. Moving to the comparative analysis between descrip- tive and metaphoric terms of the eight basic parameters, al- though for the majority of them the mean score was higher for the descriptive counterpart, no statistically significant differences were observed (p-values >0.05). Discussion This expert consensus underlines that the whole set of dermo- scopic criteria proposed by the IDS for the evaluation of skin tumors may also be used when assessing dark phototypes, apart from “clods, pink and small” and “structureless zone, pink” (and corresponding metaphoric terms, i.e., “milky-red globules” and “milky-red areas”) as “pink”/“milky-red” hue is more difficult to detect in skin of color because of the pig- mented background [6, 12]. In general, most of the variables included from the orig- inal IDS list (considering both descriptive and metaphoric 4 Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 Ta b le 1 . R es u lt s o f th e va li d at io n p ro ce ss f o r th e u se o f th e ID S d er m o sc o p ic c ri te ri a (i n cl u d in g b o th d es cr ip ti ve a n d m et ap h o ri c te rm in o lo gy ) fo r n eo p la st ic d er m at o se s in s k in o f co lo r w it h c o rr es p o n d in g ag re em en t ra te s (p er ce n ta ge o f ex p er ts g iv in g a sc o re o f 4 o r 5 ) an d m ea n s co re s fo r ea ch r o u n d D e rm o sc o p ic p a ra m e te r (D e sc ri p ti v e t e rm in o lo g y ) I R o u n d * II R o u n d * D e rm o sc o p ic p a ra m e te r (M e ta p h o ri c te rm in o lo g y ) I R o u n d * II R o u n d * 1 L in es L in es , r et ic u la r 1 0 0 ( 4 .8 3 ) - P ig m en t n et w o rk 1 0 0 ( 4 .9 1 ) - L in es , r et ic u la r an d t h ic k 1 0 0 ( 4 .7 5 ) - B ro ad en ed n et w o rk 1 0 0 ( 4 .9 1 ) - L in es , r et ic u la r an d t h in 1 0 0 ( 4 .5 8 ) - D el ic at e n et w o rk 1 0 0 ( 4 .7 5 ) - L in es , r et ic u la r an d t h ic k o r re ti cu la r li n es t h at v ar y in co lo r 1 0 0 ( 4 .6 6 ) - A ty p ic al p ig m en t n et w o rk 1 0 0 ( 4 .9 1 ) - L in es , r et ic u la r, w h it e 8 5 ( 4 .2 5 ) - - - - L in es , r et ic u la r, h yp o p ig m en te d , a ro u n d b ro w n c lo d s 9 2 ( 4 .4 1 ) - N eg at iv e p ig m en t n et w o rk 1 0 0 ( 4 .3 3 ) - L in es , w h it e, p er p en d ic u la rl y* * * 1 0 0 ( 4 .6 6 ) - Sh in y w h it e st re ak s* * * 8 4 .6 ( 4 .6 6 ) - L in es , b ra n ch ed 1 0 0 ( 4 .7 5 ) - B ra n ch ed s tr ea k s 1 0 0 ( 4 .6 6 ) - L in es , r ad ia l (a lw ay s at p er ip h er y) 1 0 0 ( 4 .8 3 ) - St re ak s 1 0 0 ( 4 .8 3 ) - L in es , r ad ia l an d s eg m en ta l 1 0 0 ( 4 .8 3 ) - R ad ia l st re am in g 1 0 0 ( 4 .6 6 ) - L in es , r ad ia l, co n n ec te d t o a c o m m o n b as e 1 0 0 ( 4 .7 5 ) - L ea fl ik e ar ea s 1 0 0 ( 4 .8 3 ) - L in es , r ad ia l, co n ve rg in g to a c en tr al d o t o r cl o d 1 0 0 ( 4 .9 1 ) - Sp o k e w h ee l ar ea 1 0 0 ( 4 .7 5 ) - L in es , c u rv ed a n d t h ic k 1 0 0 ( 4 .6 6 ) - C er eb ri fo rm p at te rn 1 0 0 ( 4 .8 3 ) - L in es , b ro w n , c u rv ed , p ar al le l, th in 1 0 0 ( 4 .6 6 ) - F in ge rp ri n ti n g 1 0 0 ( 4 .8 3 ) - L in es , c u rv ed a n d t h ic k , i n c o m b in at io n w it h c lo d s 1 0 0 ( 4 .7 5 ) - C ry p ts 1 0 0 ( 4 .8 3 ) - L in es , p ar al le l, sh o rt , c ro ss in g ri d ge s (v o la r sk in ) 1 0 0 ( 4 .8 3 ) - F ib ri ll ar p at te rn 1 0 0 ( 4 .8 3 ) - L in es , p ar al le l, th ic k , o n t h e ri d ge s (v o la r sk in ) 1 0 0 ( 4 .8 3 ) - P ar al le l ri d ge p at te rn 1 0 0 ( 4 .7 5 ) - L in es , p ar al le l, th in , i n t h e fu rr o w s an d c ro ss in g th e ri d ge s (v o la r sk in ) 1 0 0 ( 4 .8 3 ) - L at ti ce -l ik e p at te rn 1 0 0 ( 4 .7 5 ) - L in es , p ar al le l, th in , i n t h e fu rr o w s (v o la r sk in ) 1 0 0 ( 4 .8 3 ) - P ar al le l fu rr o w s p at te rn 1 0 0 ( 4 .7 5 ) - L in es , a n gu la te d o r p o ly go n al ( fa ci al s k in ) 9 2 ( 4 .5 8 ) - R h o m b o id s/ zi g- za g p at te rn 9 2 ( 4 .5 0 ) - L in es , a n gu la te d o r p o ly go n al ( n o n -f ac ia l sk in ) 9 2 ( 4 .5 0 ) - A n gu la te d l in es /p o ly go n s 9 2 ( 4 .5 2 ) - 2 C lo d s C lo d s, s m al l, ro u n d o r o va l 1 0 0 ( 4 .7 5 ) - G lo b u le s 1 0 0 ( 4 .5 0 ) - C lo d s, b ro w n , c ir cu m fe re n ti al 9 2 ( 4 .5 8 ) - R im o f b ro w n g lo b u le s 9 2 ( 4 .5 1 ) - Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 5 D e rm o sc o p ic p a ra m e te r (D e sc ri p ti v e t e rm in o lo g y ) I R o u n d * II R o u n d * D e rm o sc o p ic p a ra m e te r (M e ta p h o ri c te rm in o lo g y ) I R o u n d * II R o u n d * C lo d s, b ro w n , y el lo w , o r o ra n ge ( ra re ly b la ck ) 9 2 ( 4 .5 2 ) - C o m ed o -l ik e o p en in gs 9 2 ( 4 .4 1 ) - C lo d s, b ro w n o r b lu e, c o n ce n tr ic ( cl o d w it h in a c lo d ) 8 5 ( 4 .1 6 ) - C o n ce n tr ic g lo b u le s 9 2 ( 4 .4 2 ) - C lo d s, b ro w n , b lu e o r b la ck , c o n ce n tr ic ( cl o d w it h in a cl o d )* * - 1 0 0 ( 4 .5 3 ) C o n ce n tr ic g lo b u le s 1 0 0 ( 4 .4 2 ) - C lo d s, b ro w n o r sk in c o lo re d , l ar ge a n d p o ly go n al 1 0 0 ( 4 .5 8 ) - C o b b le st o n e p at te rn 1 0 0 ( 4 .5 0 ) - C lo d s, b lu e, l ar ge , c lu st er ed 1 0 0 ( 4 .5 2 ) - B lu e- gr ay o vo id n es ts 1 0 0 ( 4 .7 5 ) - C lo d s, b lu e, s m al l 1 0 0 ( 4 .4 1 ) - B lu e gl o b u le s 1 0 0 ( 4 .4 1 ) - C lo d s, b la ck , s m al l - 1 0 0 ( 4 .5 3 ) B la ck g lo b u le s - 1 0 0 ( 4 .5 3 ) C lo d w it h in a c lo d ( co n ce n tr ic c lo d s) 8 5 ( 4 .2 5 ) - V ar ia n t o f sp o k e w h ee l ar ea 8 5 ( 4 .3 0 ) - C lo d s, w h it e, s h in y* * * 1 0 0 ( 4 .6 6 ) - Sh in y w h it e b lo tc h es a n d s tr an d s* * * 1 0 0 ( 4 .5 6 ) - C lo d s, p in k a n d s m al l 7 2 ( 3 .9 4 ) - M il k y- re d g lo b u le s 7 2 ( 3 .9 8 ) - C lo d s, r ed o r p u rp le 9 2 ( 4 .4 1 ) - R ed l ac u n ae 9 2 ( 4 .2 3 ) - 3 D o ts * * * * D o ts , a n y co lo r 1 0 0 ( 4 .8 3 ) - G ra n u la ri ty o r gr an u le s 9 2 ( 4 .5 4 ) - D o ts , g ra y 1 0 0 ( 4 .8 3 ) - P ep p er in g 9 2 ( 4 .5 2 ) - D o ts , g ra y, b lu e o r b la ck * * - 1 0 0 ( 5 .0 ) P ep p er in g 1 0 0 ( 4 .5 2 ) - D o ts , g ra y an d c ir cl es , g ra y 1 0 0 ( 4 .6 6 ) - A n n u la r- gr an u la r p at te rn 1 0 0 ( 4 .5 8 ) - D o ts , g ra y, b lu e o r b la ck a n d c ir cl es , g ra y, b lu e o r b la ck * * - 1 0 0 ( 4 .5 3 ) A n n u la r- gr an u la r p at te rn 1 0 0 ( 4 .5 8 ) - D o ts o r cl o d s, w h it e, c lu st er ed o r d is se m in at ed 9 2 ( 4 .5 8 ) - M il ia -l ik e cy st , c lo u d y o r st ar ry 1 0 0 ( 4 .7 5 ) - D o ts , w h it e, f o u r ar ra n ge d i n a s q u ar e* * * 1 0 0 ( 4 .5 1 ) - R o se tt es * * * 9 2 ( 4 .6 6 ) - D o ts , p er ip h er al , a rr an ge d i n l in es 1 0 0 ( 4 .5 3 ) - L in ea r d o ts 8 5 ( 4 .5 2 ) - D o ts , b ro w n , c en tr al ( in t h e ce n te r o f h yp o p ig m en te d sp ac es b et w ee n r et ic u la r li n es ) 9 2 ( 4 .4 8 ) - T ar ge to id d o ts 9 2 ( 4 .3 2 ) - 4 C ir cl es C ir cl es , w h it e 9 2 ( 4 .5 8 ) - - - - C ir cl es , c o n ce n tr ic 9 2 ( 4 .1 6 ) - C ir cl e w it h in a c ir cl e 9 2 ( 4 .1 6 ) - C ir cl es , i n co m p le te 9 2 ( 4 .3 3 ) - A sy m m et ri c p ig m en te d f o ll ic u la r o p en in gs 1 0 0 ( 4 .1 2 ) - 5 P se u d o p o d s P se u d o p o d s, c ir cu m fe re n ti al o r li n es , r ad ia l, ci rc u m fe re n ti al 1 0 0 ( 4 .6 6 ) - St ar b u rs t p at te rn 1 0 0 ( 4 .6 6 ) - T ab le 1 c o n ti n u es 6 Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 D e rm o sc o p ic p a ra m e te r (D e sc ri p ti v e t e rm in o lo g y ) I R o u n d * II R o u n d * D e rm o sc o p ic p a ra m e te r (M e ta p h o ri c te rm in o lo g y ) I R o u n d * II R o u n d * 6 S tr u ct u re le ss St ru ct u re le ss z o n e, b ro w n o r b la ck 1 0 0 ( 4 .7 5 ) - B lo tc h 1 0 0 ( 4 .7 5 ) - St ru ct u re le ss z o n e, b lu e 1 0 0 ( 4 .5 8 ) - B lu e- w h it is h v ei l 1 0 0 ( 4 .6 6 ) - St ru ct u re le ss z o n e, p in k 7 5 ( 3 .9 5 ) - M il k y- re d a re as 7 2 ( 3 .8 6 ) - St ru ct u re le ss z o n e, w h it e 1 0 0 ( 4 .8 3 ) - Sc ar -l ik e d ep ig m en ta ti o n 1 0 0 ( 4 .7 5 ) - St ru ct u re le ss z o n e, w h it e, c en tr al 1 0 0 ( 4 .8 3 ) - C en tr al w h it e p at ch 1 0 0 ( 4 .6 6 ) - St ru ct u re le ss z o n e, p o ly ch ro m at ic 8 5 ( 4 .3 3 ) - R ai n b o w p at te rn 9 2 ( 4 .4 1 ) - St ru ct u re le ss , r ed , i n te rr u p te d b y fo ll ic u la r o p en in gs 8 2 ( 4 .1 6 ) - St ra w b er ry p at te rn 8 5 ( 4 .2 3 ) - St ru ct u re le ss , b ro w n ( ta n ), e cc en tr ic 1 0 0 ( 4 .5 8 ) - - - - St ru ct u re le ss , a n y co lo r 1 0 0 ( 4 .7 5 ) - H o m o ge n eo u s p at te rn 1 0 0 ( 4 .8 3 ) - St ru ct u re le ss , b ro w n , i n te rr u p te d b y fo ll ic u la r o p en in gs (f ac ia l sk in ) 1 0 0 ( 4 .6 6 ) - P se u d o n et w o rk 1 0 0 ( 4 .6 6 ) - 7 E ls e Sh ar p ly d em ar ca te d , s ca ll o p ed b o rd er 1 0 0 ( 4 .6 6 ) - M o th -e at en b o rd er 1 0 0 ( 4 .7 5 ) - F o ll ic u la r p lu gs - 9 2 ( 4 .6 9 ) - - - E ro si o n s/ U lc er at io n s - 1 0 0 ( 4 .8 4 ) - - - 8 V es se ls 8 .1 M o rp h o lo gy D o ts 1 0 0 ( 4 .7 5 ) - - - - C lo d s 1 0 0 (4 .3 8 ) - R ed -p u rp le l ac u n es 1 0 0 ( 4 .4 6 ) - L in ea r 1 0 0 ( 4 .7 5 ) - - - - C o il ed 1 0 0 ( 4 .5 8 ) - G lo m er u la r 1 0 0 ( 4 .5 0 ) - L o o p ed 1 0 0 ( 4 .6 6 ) - H ai rp in 1 0 0 ( 4 .7 5 ) - Se rp en ti n e 1 0 0 ( 4 .5 0 ) - L in ea r ir re gu la r 1 0 0 ( 4 .5 8 ) - H el ic al 1 0 0 ( 4 .5 0 ) - C o rk sc re w 1 0 0 ( 4 .5 8 ) - C u rv ed 1 0 0 ( 4 .4 4 ) - C o m m a 1 0 0 ( 4 .4 1 ) - M o n o m o rp h o u s 9 2 ( 4 .4 1 ) - - - - P o ly m o rp h o u s 1 0 0 ( 4 .7 5 ) - - - - Ta b le 1 . R es u lt s o f th e va li d at io n p ro ce ss f o r th e u se o f th e ID S d er m o sc o p ic c ri te ri a (i n cl u d in g b o th d es cr ip ti ve a n d m et ap h o ri c te rm in o lo gy ) fo r n eo p la st ic d er m at o se s in s k in o f co lo r w it h c o rr es p o n d in g ag re em en t ra te s (p er ce n ta ge o f ex p er ts g iv in g a sc o re o f 4 o r 5 ) an d m ea n s co re s fo r ea ch r o u n d ( co n ti n u ed ) Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 7 D e rm o sc o p ic p a ra m e te r (D e sc ri p ti v e t e rm in o lo g y ) I R o u n d * II R o u n d * D e rm o sc o p ic p a ra m e te r (M e ta p h o ri c te rm in o lo g y ) I R o u n d * II R o u n d * 8 .2 A rr an ge m en t R ad ia l 1 0 0 ( 4 .6 6 ) - C ro w n v es se ls 9 2 ( 4 .5 0 ) - Se rp ig in o u s 1 0 0 ( 4 .6 6 ) - St ri n g o f p ea rl s 1 0 0 ( 4 .6 6 ) - B ra n ch ed 1 0 0 ( 4 .7 8 ) - A rb o ri zi n g ve ss el s 1 0 0 ( 4 .8 3 ) - C lu st er ed 1 0 0 ( 4 .8 3 ) - - - - C en te re d d o ts 1 0 0 ( 4 .6 1 ) - T ar ge to id v es se ls 1 0 0 ( 4 .6 3 ) - 8 .3 W h it e co lo r ar o u n d v es se ls - 1 0 0 ( 4 .5 3 ) P er iv as cu la r w h it e h al o - 1 0 0 ( 4 .6 1 ) * A gr ee m en t ra te ( m ea n s co re ) – A gr ee m en t ra te i s m ea su re d f ro m 0 % t o 1 0 0 % , m ea n s co re i s m ea su re d f ro m 0 t o 5 ; * * T h is p ar am et er r ep la ce s th e p re vi o u s o n e. * * * O n ly v is ib le b y p o la ri ze d d er m o sc o p y. * * * * D o ts a n d c lo d s ca n b e b es t d if fe re n ti at ed i f th ey a p p ea r as a p at te rn . M u lt ip le d o ts h av e th e sa m e si ze a n d s h ap e (t h ey a re a ll s m al l an d r o u n d ), m u lt ip le c lo d s va ry i n s iz e an d s h ap e. I n g en er al d o ts a re n o t la rg er t h an t h e d ia m et er o f a te rm in al h ai r. 7 8 Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 change in the morphology of some structures (e.g., “incom- plete” may become “complete” pigmented circles). This is in line with evidence from the literature. For example, blurred vascular structures and “reticular white lines”/“lines, reticu- lar, hypopigmented, around brown clods” (negative pigment network), commonly found respectively in dermal nevi and dermatofibromas in light phototypes, have been reported less frequently in skin of color [13-15]. On the other hand, homogeneous pigmentary findings (excluding concentric and polychromatic items) and white structures were generally rated high (> 4.5). This is easily explained as diagnosis of skin tumors in dark-skinned pa- tients mainly relies on the prevalence and combination of such features [16]. Additionally, some vessel shapes/arrange- ments also reached a high score, especially dotted/linear morphologies and clustered/branched distribution patterns, likely resulting from the significant prevalence of these find- ings in Bowen’s disease and basal cell carcinoma also in skin of color [17, 18]. Besides dermoscopic items included in the original list of the IDS, panelists also proposed and agreed on the introduc- tion of four new variables for the assessment of skin tumors in dark phototypes, including “clods, black, small” (black terminology) received a high mean rate (between 4.5 and 5), with only a few of them reaching agreement with a lower score (< 4.5). In detail, the latter group included the follow- ing descriptive items: “reticular white lines” and “lines, retic- ular, hypopigmented, around brown clods” in the “LINES” category; “clods, brown or blue, concentric (clod within a clod)”, “clods, blue, small”, “clod within a clod (concentric clods)” and “clods, red or purple” in the “CLODS” param- eter; “dots, brown, central (in the center of hypopigmented spaces between reticular lines)” in the “DOTS” category; “circles, concentric” and “circles, incomplete” when it comes to the “CIRCLES” parameter; “structureless zone, poly- chromatic” and “structureless, red, interrupted by follicular openings” considering the “STRUCTURELESS” category; and “clods”, “curved” and “monomorphous” morphol- ogy in the “VESSELS” parameter. The reasons underlying a lower scoring for such variables mainly include the higher melanin content and the greater tendency to pigmentary in- continence typical of darker phototypes [6] that may result in lower optical contrast (needed to optimally see concen- tric, polychromatic or pigmented structures) or the partial obscuration of some findings (e.g., red/purple structures, smaller/thinner vessels, or hypopigmented lines) as well as Figure 1. Schematic representation of newly-introduced dermoscopic parameters to use in skin of color: black, small clods (black globules) (a); follicular plugs (b); erosions/ulcerations (c); and white color around vessels (perivascular white halo) (d). Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 9 Figure 2. Examples of skin tumors in dark-skinned patients (phototypes V/VI) typified by the newly-introduced dermo- scopic structures: black, small clods (black globules) in a seborrheic keratosis (arrows) (a); follicular plugs in an actinic keratosis (arrows) (b); erosions in a basal cell carcinoma (arrows) (c); and white color around vessels (perivascular white halo) in a squamous cell carcinoma (d). Figure 3. Schematic representation of modified dermoscopic parameters to use in skin of color: “clods, brown, blue or black, concen- tric” (clod within a clod) (a); “dots, gray, blue or black” (peppering) (b); and “dots, gray, blue or black and circles, gray, blue or black” (annular-granular pattern) (c). Figure 4. Examples of skin tumors in dark-skinned patients (phototypes V/VI) typified by the modified dermoscopic parameters: black/ brown concentric clods (black clod within a brown clod) in a basal cell carcinoma (arrows) (a); “blue/black dots” (blue/black peppering) in a melanoma (arrows) (b); and “blue/black dots and circles” (blue/black annular-granular pattern) in a lentigo maligna (arrows) (c). 10 Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 intended to be the starting point to fill the existing knowl- edge gap in the field of dermoscopy of skin tumors in skin of color as it might help facilitate the interpretation of reported findings and increase the reproducibility of the studies. Limitations The present validation process was based on the Delphi tech- nique, which relies on the opinion of a group of experts, so the results represent the point of view of a limited number of evaluators. Additionally, albeit all the included panelists routinely deal with dark-skinned patients, an interobserver variability does exist in terms of the proportions of each phototype. References 1. Errichetti E, Stinco G. Dermoscopy in General Dermatology: A Practical Overview. Dermatol Ther (Heidelb) 2016;6:471-507. 2. Fee JA, McGrady FP, Rosendahl C, Hart ND. Training Primary Care Physicians in Dermoscopy for Skin Cancer Detection: a Scoping Review. J Cancer Educ 2020;35:643-50. 3. Errichetti E. Dermoscopy of Inflammatory Dermatoses (Inflam- moscopy): An Up-to-Date Overview. Dermatol Pract Concept 2019;9:169-80. 4. Errichetti E, Zalaudek I, Kittler H, et al. Standardization of dermoscopic terminology and basic dermoscopic parameters to evaluate in general dermatology (non-neoplastic dermatoses): an expert consensus on behalf of the International Dermoscopy So- ciety. Br J Dermatol 2020;182:454-67. 5. Kittler H, Marghoob AA, Argenziano G, et al. Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermos- copy. J Am Acad Dermatol 2016;74:1093-106. 6. Errichetti E, Ankad BS, Sonthalia S, et al. Dermoscopy in gen- eral dermatology (non-neoplastic dermatoses) of skin of colour: a comparative retrospective study by the International Dermos- copy Society. Eur J Dermatol 2020;30:688-98. 7. Errichetti E. Dermoscopy of common papulosquamous derma- toses varies between dark (III and IV) and very dark (V and VI) skin phototypes. Dermatol Ther 2021;34:e14757. 8. Errichetti E, Ankad BS, Jha AK, et al. International Dermoscopy Society criteria for non-neoplastic dermatoses (general dermatol- ogy): validation for skin of color through a Delphi expert con- sensus. Int J Dermatol 2022;61:461-71. 9. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs 2000;32:1008-15. 10. Lynn MR. Determination and quantification of content validity. Nurs Res 1986;35:382-5. 11. Graefe A, Armstrong JS. Comparing face-to-face meetings, nomi- nal groups, Delphi and prediction markets on an estimation task. Int J Forecasting 2016;27:183-95. 12. Ankad BS, Sakhare PS, Prabhu MH. Dermoscopy of non-melanocytic and pink tumors in brown skin: A descriptive study. Indian J Dermatopathol Diagn Dermatol 2017;4:41-51. 13. Lallas A, Reggiani C, Argenziano G, et al. Dermoscopic nevus patterns in skin of colour: a prospective, cross-sectional, mor- phological study in individuals with skin type V and VI. J Eur Acad Dermatol Venereol 2014;28:1469-74. globules), follicular plugs, erosions/ulcerations, and white color around vessels (perivascular white halo), histologically related to melanin deposits/melanocytes in the epidermis, follicular hyperkeratosis, loss of epidermis/dermis, and ac- anthosis, respectively. This was due to their significant diag- nostic relevance (e.g., follicular plugs are a key clue in actinic keratosis/SCC as they often show a pigmentary pattern sim- ilar to lentigo maligna/melanoma – see Figures  2b,4c) but also to the higher prevalence of such structures in skin of color (as the result of a greater tendency to darker pigmen- tation and follicular/ulcerative reactions as well as a greater contrast between the perivascular white halo and surround- ing pigmented skin) [6, 19]. Moreover, during the consensus process a change of three existing parameters (i.e., “dots”, “clod within a clod”, and “dots and circles”) was also in- cluded, with darker colors (blue/black) being listed as a pos- sible additional hue for the aforementioned structures, still due to the higher tendency to have more prominent pigmen- tation in dark phototypes [6, 19]. Finally, the comparative analysis between descriptive and metaphoric terminology highlighted no relevant differences in terms of mean score for each of the eight basic parameters, thereby underlying that both of them are useful and might be complementary. In fact, the metaphoric approach is more re- lated to “blink” (quick) diagnoses (e.g., “arborizing” vessels are a quick hint for a basal cell carcinoma), while descriptive assessment is extremely helpful when “blink” fails in describ- ing a lesion and a more analytical process is needed for a correct dermoscopic diagnosis [20, 21]. The lack of a clear predominance between the two approaches is also empha- sized by the consistency observed in the present consensus process when considering the rating of each descriptive item and corresponding metaphoric counterpart (<4.0; 4÷4.5; >4.5), with the only exception of “comedo-like openings”. Indeed, this item was rated lower than the corresponding descriptive terminology, likely because it has a weaker cor- respondence from a morphological point of view in skin of color as the lower optical contrast typical of dark phototypes often makes epidermal invaginations filled with keratin look like darkly pigmented globules rather than “comedo-like openings” [12]. Conclusions To conclude, the present validation process provides struc- tured dermoscopic criteria for the assessment of skin tumors in dark phototypes based on parameters proposed by the IDS. Albeit most of the original items were considered appli- cable even for skin of color, there are some points of differ- ences that physicians need to know. Notably, no significant preference was found between descriptive and metaphoric terminology. The set of criteria validated in this consensus is Original Article | Dermatol Pract Concept. 2023;13(1):e2023067 11 18. 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Kelati A, Aqil N, Baybay H,  et al.  Beyond classic dermoscopic patterns of dermatofibromas: a prospective research study. J Med Case Reports 2017;11:266.s 16. Ezenwa E, Stein JA, Krueger L. Dermoscopic features of neo- plasms in skin of color: A review. Int J Womens Dermatol 2021;7:145-51. 17. Vinay K, Ankad BS, Narayan VR, et al. A multicentric study on dermoscopic patterns and clinico-dermoscopic-histological cor- relates of basal cell carcinoma in Indian skin. Clin Exp Dermatol 2022 Jul 22. doi: 10.1111/ced.15337.