Clinical and dermoscopic triage of head and neck macules: The role of reflectance confocal microscopy in a prospective study of 2006 lesions

Background Flat head/neck pigmented macules can be diagnostically challenging. Objective To assess the impact of reflectance confocal microscopy (RCM) integration to dermoscopic triage of equivocal lesions. Methods Prospective multicenter study of equivocal flat macules. Lesions suspicious or discordant were biopsied/excised; double-negative lesions were followed ≥1 year. Histopathology served as reference standard. Results A total of 2006 lesions from 801 patients (mean age 66.2 years) were evaluated. After dermoscopy–RCM integration, 236/2006 (11.8%) lesions were managed as malignant (226 biopsied/excised; 10 noninvasively treated: 8 basal cell carcinoma [BCC] and 2 lentigo maligna [LM]). Twenty-six lesions changed at follow-up and were removed, with 4 malignancies (0.4%; 3 LM, 1 BCC). Histology (n = 252) confirmed 114 malignancies (62 LM/lentigo maligna melanoma [LMM]; 52 BCC/squamous cell carcinoma [SCC]). Dermoscopy detected 54.8% of LM/LMM and 90.4% of BCC/SCC; RCM correctly diagnosed 91.9% of LM/LMM and 94.2% of BCC/SCC. Limitations Verification and selection biases and follow-up losses. Conclusion Integrating RCM significantly improves LM/LMM sensitivity detection and specificity for benign lesions compared to dermoscopy alone, minimizing overtreatment and missed malignancies. Although a small residual risk of missed malignancy persists, the combined approach offers a highly safe, noninvasive pathway for managing equivocal lesions in cosmetically sensitive areas.