What does this research mean for the field?

The integration of dermoscopy and reflectance confocal microscopy significantly enhances the noninvasive preoperative classification of basal cell carcinoma subtypes, improving diagnostic accuracy. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

What question did this study set out to answer?

This study aims to enhance the diagnostic accuracy of basal cell carcinoma subtyping using noninvasive imaging techniques.

February 16, 2026Open Access

Improving Basal Cell Carcinoma Subtype Diagnosis with Dermoscopy and Reflectance Confocal Microscopy: A Multicenter Prospective Study

Key Points

This study aims to enhance the diagnostic accuracy of basal cell carcinoma subtyping using noninvasive imaging techniques.
Conducted a multicenter prospective study across three centers in Northern Italy.
Analyzed 281 histologically confirmed BCCs from 256 patients using clinical, dermoscopic, and RCM evaluations.
Recorded subtype-specific features and correlated them with histopathology.
Assessed interobserver agreement using Cohen’s kappa.
Evaluated diagnostic performance via sensitivity, specificity, and AUC.
Fifteen percent of BCCs were superficial, 38% nodular, and 47% infiltrative.
Diagnostic accuracy improved with the combination of dermoscopy and RCM.
Sensitivity for superficial BCC increased from 74.4% to 81.4%, specificity from 97.9% to 98.3%.
AUC reached 0.899, indicating high diagnostic performance.

Abstract

Abstract Introduction Basal cell carcinoma (BCC) is the most prevalent form of skin cancer. Accurate histological subtyping is essential for appropriate therapeutic planning, particularly for infiltrative variants associated with higher recurrence rates. Noninvasive imaging modalities such as dermoscopy and reflectance confocal microscopy (RCM) may enhance the diagnostic precision of BCC subtyping prior to treatment. Methods This was a prospective multicenter study conducted between August 2017 and June 2019 across three centers in Northern Italy. A total of 281 histologically confirmed BCCs from 256 patients were analyzed. Each lesion underwent standardized clinical, dermoscopic, and handheld RCM evaluation prior to biopsy. Subtype-specific features were recorded and correlated with histopathology. Interobserver agreement was assessed using Cohen’s kappa, and diagnostic performance was evaluated via sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). Results Among the 281 BCCs, 15% were superficial, 38% nodular, and 47% infiltrative. Dermoscopically, superficial BCCs exhibited brown globules and shiny white-red structureless areas; nodular BCCs presented blue structures, arborizing vessels, and ulceration; infiltrative BCCs showed white porcelain areas and lacked pigmentation. RCM identified streaming and cords in superficial BCCs (p=0.003; 3-fold risk), large tumor islands in nodular BCCs, and dark silhouettes in infiltrative BCCs (p=0.005; 2–3-fold risk). Diagnostic accuracy improved with combined dermoscopy and RCM. Sensitivity for superficial BCC increased from 74.4% (95% CI 60.2–85.8) to 81.4% (95% CI 68.1–91.0), specificity from 97.9% (95% CI 95.5–99.5) to 98.3% (95% CI 96.1–99.5), and AUC reached 0.899. Conclusions The integration of dermoscopic and RCM findings significantly enhances the noninvasive preoperative classification of BCC subtypes. This approach improves diagnostic accuracy and may inform more precise, subtype-tailored management, reducing treatment failures and supporting personalized dermatologic care.

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