DOI: 10.1111/j.1468-3083.2010.03837.

x JEADV

REVIEW ARTICLE

Principles of high-frequency ultrasonography for

investigation of skin pathology
D Jasaitiene,†,* S Valiukeviciene,† G Linkeviciute,† R Raisutis,‡ E Jasiuniene,‡ R Kazys‡
†
Department of Skin and Venereal Diseases of Kaunas University of Medicine, Kaunas, and ‡Ultrasound Institute, Kaunas
University of Technology, Kaunas, Lithuania
*Correspondence: D Jasaitiene. E-mail: odos.veneriniu.ligu.klinika@kmuk.lt

Abstract
Ultrasonography is a valuable diagnostic tool widely used in medicine. During the last three decades, this non-
invasive skin imaging method has been extended to dermatology. High-frequency ultrasonography with higher than
20 MHz scanners is well-established for measuring tumour thickness and skin thickness when treating inflammatory
skin diseases such as scleroderma or psoriasis. High-frequency ultrasonography has become extremely helpful for
the preoperative assessment of skin melanoma. The correlation between ultrasonic and histological measurements
of melanomas thickness is significantly similarly good using transducers of 20, 75 or 100 MHz frequency (r range
from 0.895 to 0.99) and better compared with transducers of 7.5 MHz frequency (r = 0.76). The preoperative
sonographically estimated thickness of skin melanoma is sometimes overestimated, because of an underlying
inflammatory infiltrate and other reasons. Assessment of skin melanoma thickness using transducers of 100 MHz
frequency has better agreement with histology, compared with ultrasonography with 20 MHz transducers. However,
the ultrasonic penetration depth is limited to 1.5 mm in case of 100 MHz. The newer ultrasonic techniques such as
high-frequency ultrasonography and colour Doppler sonography could be used for assessment of the tumour
vascularization and its metastatic potential. The wide variety of diagnostic information provided by high-frequency
ultrasonography undoubtedly improves the management of oncological and inflammatory skin conditions and
underlines its essential position in dermatological practice.
Received: 1 April 2010; Accepted: 5 August 2010

Keywords
dermatology, imaging, skin, tumours, ultrasonography, ultrasound

Conflicts of interest
None declared.

Introduction Subsequently, transducers with ultrasound frequencies of 100 and

Since the introduction of ultrasonography into medical diagnostics
about 50 years ago, this technique has grown to become the most
frequent imaging method in medicine. This is attributed to its ver-
satility, unlimited repeatability with high diagnostic value and the
lack of risk to the patient. This article reviews the applications of
ultrasonography in dermatology focusing on preoperative mea-
surement of tumour thickness.
Ultrasonography for measuring skin thickness was for the first
time performed by Alexander and Miller using an A-mode device
in 1979.1 Great progresses in the development of high-frequency
scanners occurred since that time. Studies on B-mode ultrasonog-
raphy of the skin using 20 megahertz (MHz) prototypes followed
in the next decades in Europe and Japan. These appliances have
A-, B- and C-scans, optional 3D reconstruction, and further
transducers with 30 and 50 MHz frequency at their disposal.
150 MHz were developed that could depict the fine structure of the
epidermis, and their clinical value is currently under evaluation.2–7
Fundamental physics and ultrasound phenomena
Ultrasound is elastic waves with frequency above 20 kHz, which
represents the upper frequency limit of human hearing. Ultrasonic
waves are generated by an ultrasonic transducer that can transform
an electrical current of the driving generator into a mechanical
vibration. Thus, a very short ultrasound impulse is created. Vibra-
tions from the ultrasonic transducer are transmitted into the med-
ium under investigation and propagate in the form of an
ultrasonic wave. The propagation speed of ultrasonic wave is
denoted by ultrasound velocity in the medium. The ultrasonic
wave is partially reflected at an interface separating two media of
different acoustic impedance. The reflected wave is detected by the

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376
same transducer the mechanical vibration being transformed into
electrical excitation.5,6
Ultrasonic transducers – which are thin disc-shaped crystals
made out of piezoelectric materials – generate acoustic energy
when a voltage is applied to them. Acoustic vibrations are gener-
ated when those piezoelectric materials expand and contract. First
transducers were made from quartz; newer materials include lith-
ium sulphate, ceramics and plastic polymers. These newer materi-
als have allowed the development of transducers that produce
higher frequencies, which are of special interest for dermatologists
because the wavelengths of higher frequencies are smaller and
therefore better resolution of small objects located near the skin
surface is achieved.6 At present, the transducers for examination of
regional lymph nodes and soft tissue tumours operate in the 7.5–
15 MHz range, while the frequency of transducers used to evaluate
skin structure is in the range from 20 to 100 MHz.
Usually, ultrasound velocity in the human skin is reduced when
the water content of the tissue is greater, and is increased when
the collagen concentration is higher. Several ultrasonic velocity
values have been reported for human skin, ranging from 1498 up
to 1710 m ⁄ s.5 According to the information provided by Wei-
chenthal et al., in the tissue of human skin affected by melanoma
the ultrasound velocity deviates only by 1% from the value
obtained in the case of healthy skin.5,8
If the ultrasound velocity in the skin is known, it is possible to
calculate skin and ⁄ or tumour thickness in vivo, from the expres-
sion l ¼ c  t=2, where t is the time separating echoes generated by
the external medium–epidermis interface and the dermis–subcutis
interface, and c is ultrasonic velocity. The maximum thickness of
epidermis is up to 0.3 mm and of dermis – up to 2.5 mm.9 In the
case when pulse-echo set-up is used, ultrasonic waves propagate
through the skin and are reflected back. Normal and diseased skin
thickness has been measured in vivo by ultrasound.5,10
The attenuation of an ultrasonic wave during propagation is the
reduction in vibration amplitude and the intensity of the wave
during propagation. This reduction results from the absorption of
the ultrasonic energy by the tissue and its transformation into
heat, from the natural divergence of the ultrasonic waves related
to the geometry of the transducer, and to the diffusion (scattering)
of the wave because of the heterogeneity of the tissue being propa-
gated. It increases when the frequency used is higher. This prop-
erty is used to characterize tissue according to its physical
properties, in particular by measuring ultrasound attenuation. In
addition, the attenuation limits the depth of penetration because
the higher the central frequency, the smaller the depth of penetra-
tion is.5,11
In the case of skin investigation, it is necessary to distinguish
the different layers – epidermis, dermis and subcutis. The axial res-
olution is measured in the direction of the propagation of the
ultrasonic wave, which is excited perpendicular to the surface of
the skin by the ultrasonic transducer. It is the shortest distance
separating the layers of the skin that the ultrasonic device is able
JEADV 2011, 25, 375–382 Journal of the European Academy of Dermatology and Venereology ª 2010 European Academy of Dermatology and Venereology
Jasaitiene et al.
Table 1 The dependence of axial (depth) resolution and pene-
tration depth on the frequency of ultrasonic waves
Frequency, Maximum Axial resolution
MHz penetration, (1580 m ⁄ s ⁄
mm frequency), lm
10 35 158
20 10 79
30 6 53
50 4 32
75 3 21
100 1.5 16
to distinguish. The lateral resolution is measured perpendicular to
the direction of wave propagation, i.e. parallel to the skin. Axial
resolution is limited physically by the wavelength. The ultrasound
velocity (c), frequency (f) and the wavelength (k) are related:
k ¼ c=f . Shorter wavelength is required to achieve better axial res-
olution. Axial resolution also depends on the bandwidth of the
transducer. Lateral resolution depends on the diameter and central
frequency of the transducer, the width of the beam at the focus
zone and the spatial scanning step of the ultrasonic transducer.5
The relationship of axial resolution and penetration depth with
the frequency of ultrasonic waves used for the investigation of
human skin is presented in Table 1.5,11
Imaging techniques
Usually, the result of ultrasonic imaging is presented in the form
of A-scan (measurement at one point, showing the thickness of
different layers of the skin), B-scan [two-dimensional (2D), cross-
sectional view of the skin] and C-scan (2D view at some depth
parallel to the surface of the skin) images.4–6 The principles of
ultrasonic imaging of the skin structure are presented in Fig. 1.
A-scan image of the skin reveals the amplitude of the echo
reflected by the interfaces between layers of the skin (dermis–sub-
cutis, normal tissue-tumour). The different echoes recorded on-
line are of different amplitudes and are recorded according to a
time scale. The time of acoustic wave propagation is related to the
distance. A-scan imaging is used to measure skin thickness in vivo.
From the velocity of ultrasonic waves in the skin (the mean value
equal to 1600 m ⁄ s) and the time taken for the propagation of the
ultrasonic signal, it is possible to calculate the thickness of the
skin.5,12
B-scan image is a 2D scan procedure using the same principle
as A-scan, but combined with longitudinal scanning, the combina-
tion of which provides acquisition of several A-scans side by side.
The amplitudes of such group of A-scans are represented by
appropriate colour (shade) in 2D echographic image of the section
of the skin. In this type of image, the different shades of grey
depend on the echo (strength) detected from the corresponding
anatomic structure. Such type of imaging is important in nowa-
days dermatological research and clinical dermatology. It provides
an echographic image of the internal structure of the skin and
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Principles of high-frequency ultrasonography 377

(a) Measurement point distinguishes the epidermis, papillary and reticular dermis, and
pilosebaceous units and subcutis.5,12
C-scan image is conventionally displayed as a 2D image but is
reconstructed from a three-dimensional data set which is obtained
from several B-scan images. Computerized reconstruction of data
obtained at such parallel cross-sections provides reconstruction of
the skin structure, as long as they are precisely identified in space.
This is particularly valuable for the reconstruction of tumours.5

Technical equipment
(b) Ordinary ultrasonic equipment for skin investigation consists of
an ultrasonic transducer of sufficiently high frequency (about
Imaging plane 15 MHz), an ultrasonic unit of excitation, reception and digitiza-
tion, and a computer for the control of data acquisition and visu-
alization. The transducer should be moved along the scanning axis
to obtain 2D ultrasonic image (B-scan imaging). Movement is
achieved with a small DC motor. The motor is linked with an
ultrasonic unit of excitation, reception and digitization. Particular
position of the ultrasonic transducer in the scanning path is esti-
mated using a position encoder. In the case of C-scan imaging, the
ultrasonic transducer should be moved along two independent
axes that are perpendicular to each other, and therefore two DC
(c) motors and position encoders should be used. As a result of the
large impedance mismatch between the air and the skin, the cou-
pling liquid (gel) between the transducer and the surface of the
skin should be used.5
For higher frequency ultrasonic examinations, there are differ-
ent ultrasound systems available in the market, for example: the
Imaging plane Episcan I-200 (Longport, Inc, Silchester, UK), the DermaScan C
(Cortex Technology, Hadsund, Denmark) and the DUB-USB
Figure 1 The principles of ultrasonic imaging of the skin struc- (Taberna pro medicum, Luneburg, Germany). The characteristics
ture: (a) A-scan, (b) B-scan and (c) C-scan. of the commercially available ultrasonic equipment for skin inves-
tigation are presented in Table 2.

Table 2 Characteristics of the commercially available 20–50 MHz frequencies ultrasonic equipment for skin investigation (2D imag-
ing, B-scan)

Equipment, manufacturer Episcan I-200, DermaScan C, Cortex DUB-USB, Taberna

Longport, Inc. Technology pro medicum
Analogue-to-digital converter 200 MHz, 8 bits (256 levels – 100 MHz, 8 bits (256 levels of
of amplitude) amplitude)
Scan (penetration) depths, mm 3.8–22.4 10–20 (depends on focal 8–10
distance of the transducer)
Axial resolution, lm Up to 40 60 72
Lateral resolution, lm – 130 –
Central frequency of the 20, 50 20 22
transducer, MHz
Scan lateral length, mm 15 – 12.8
Scan rate, frame per second 1 8 2.5
Type of visualization A-scan, B-scan (envelopes) A-scan, B-scan (envelopes) A-scan, B-scan (envelopes)
Combination with PC Combined with embedded Combined with embedded Separate portable device,
PC in minitower design PC in minitower design connection with PC via
USB 2.0
–, no information available.

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All transducers of such equipment are scanned mechanically,
and the coupling water-like liquid is applied in all cases. 2D scan-
ners for B-scan imaging are available in portable configurations
for use with handheld ultrasonic transducers. Scanners for C-scan
imaging, combined with flexible arm holding the scanning head,
usually are installed into a specialized transportation cart and are
not portable. The price of such system is sufficiently high. More-
over, only one portable 2D scanning system DUB-USB is assem-
bled as a separate device that can be connected with any PC via
USB 2.0 interface. Other portable 2D systems are combined with
PC in the same non-demountable assembly. To our knowledge,
the commercially available ultrasonic equipment evaluated during
literature review has some limitations from the viewpoint of the
investigation of skin thickness and structures.13–17 Usually, only
envelope of the signal is being visualized. A large amount of infor-
mation is lost from the raw radiofrequency (RF) signal, and the
RF signal is not accessible to the user for further processing and
analysis. A small number of scale values is being visualized – typi-
cally, 256 levels of amplitude (48 dB), only 8 bits. Moreover, usu-
ally the sampling frequency does not exceed 100 MHz. The review
of ultrasonic systems that are used in dermatological practice and
suggestions how to improve them are published recently.18 It
should be noticed that a capacitive micromachined ultrasonic
transducers are used more and more in the field of high-frequency
arrays (up to 50 MHz), and therefore they are becoming very per-
spective in medical imaging. Such arrays have wide bandwidth
and would allow the use of dynamic focusing and higher frame
rates.19
Investigation of skin tumours
Ultrasonography using ultrasonic transducers of 15 MHz fre-
quency or more can clearly define the skin layer morphology
including changes in the epidermal thickness.20 Thus, adjustments
of focus, transmission frequency, or both give – in a single exam-
ination – a complete view of the skin and deeper structures
(muscles, tendons or bone margins), with minimal dispersion of
the sound energy waves.21–23
In skin cancer – especially melanoma – preoperative ultrasono-
graphic measurement of tumour thickness could be an important
parameter for planning surgery and predicting the prognosis for
the patient. Even if some inaccuracy in measurement of thin
(pT < 0.4 mm) or very thick tumours (pT > 7.6 mm) in compar-
ison with histology has been shown, distinguishing between thick
(>1 mm) and thin melanomas is important for determining safety
margins for the excision of the primary tumour and for the indi-
cation for sentinel lymph node biopsy in a potential one-time
surgical procedure.24–27
A fair correlation (r ‡ 0.9) between ultrasonic and histological
measurements of melanoma thickness was obtained by many
authors (Table 3). Most of these ultrasonographic studies used
20 MHz probes. Results of several studies that have used ultra-
sonic transducers of 7–15 MHz frequencies for assessment of
JEADV 2011, 25, 375–382 Journal of the European Academy of Dermatology and Venereology ª 2010 European Academy of Dermatology and Venereology
Jasaitiene et al.
the thickness of melanomas and basal cell carcinomas showed
lower correlation between ultrasonometric and histometric
thickness.28–32 Overestimation of skin tumour thickness resulting
from the impossibility of differentiating lymphocytic infiltrates
or underlying nevus cells from melanoma tissue has been
reported.33,34 The location of skin tumours in some areas (the
head, nail and genitalia) can influence the ultrasonographic over-
estimation as well.31 Routine histology using conventional for-
malin-paraffin processing frequently distorts the anatomy of the
horny layer and may result in artefacts including shrinkage of
the tissue.35 A further important factor that may explain differ-
ences between in vivo and ex vivo measurements is the natural
shrinkage of the skin occurring after excision, particularly evident
for the dermis.35 Some melanomas are too thin (0.1 mm) to
be visualized with 20 MHz ultrasound.36,37 The lowest ultraso-
nometric accuracy was observed in melanomas with a tumour
thickness smaller than 1 mm.24,26,29,33 It has been indicated
that thickness assessed by ultrasonography in thin tumours
can be overestimated (in 15%), and in thick ones – underesti-
mated (in 7%).29 Transducer of 100 MHz frequency possesses
the capability of high resolution imaging up to 1.5 mm depth
of penetration with a much better resolution than the well-
established 20 MHz technique, and tumour thickness measure-
ments of thin melanomas using transducer of 100 MHz results
in better agreement with histology, compared with transducer
of 20 MHz frequency.35 However, the penetration depth is
limited to 1.5 mm in case of 100 MHz.
Ultrasonography is a non-invasive technique and thus should
be ideally suited for preoperative assessment of invasion depth of
skin tumours, and has a high degree of accuracy, as shown by
linear regression analysis (Pearson’s correlation coefficient r)
(Table 3). Bland and Altman have pointed out that when a com-
parison of two clinical measurements of the same criterion is
made, the use of the correlation may be misleading.38 The correla-
tion coefficient measures the strength of the relationship between
the variables but does not necessarily measure the agreement
between them. Bland and Altman agreement includes the numeri-
cal identity between the test results of two different methods, uses
the differences between the paired measurements, and is suggested
to be a more useful indication as to whether one method can be a
valid substitution for another.38 This statistical analysis shows that
ultrasonography usually generates higher value for tumour thick-
ness compared with conventional thickness measurement.35 More-
over, Tacke et al. revealed greater differences between sonometry
and histometry calculating absolute and relative differences
between them.39
Some studies demonstrated that the number and size of vessels
visualized with colour Doppler sonography (CDS) significantly
correlate with evaluation of vessels by immunochemical methods
and the rate of metastasis of melanoma.29,34,40 Therefore, intra-
tumour angiogenesis evaluated with CDS could be used to identify
melanomas with a high metastatic potential. However, this helpful
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Principles of high-frequency ultrasonography 379

Table 3 Correlation between the histological and ultrasound estimation of skin tumour thickness

Investigators, year Frequency of Studied skin tumours Correlation*

ultrasound (MHz)
50
Reali et al., 1989 20 Melanomas (N = 58) Yes (r = 0.895)
51
Gassenmaier et al., 1990 20 Melanomas (N = 72) Yes (r = 0.97)
52
Hoffman et al., 1992 20 Melanomas (N = 54) Yes (r = 0.94)
36
Fornage et al., 1993 20 Malignant (N = 45, including four melanomas) Yes (r = 0.95) for melanomas
and benign (N = 155) skin lesions
39
Tacke et al., 1995 20 Melanomas (N = 259) Yes (r = 0.88)
53
Partsch et al., 1996 20 Melanomas (N = 58) Yes (r = 0.92)
33
Krahn et al., 1998 20 Melanomas (N = 39), Yes (r = 0.95 and r = 0.93)
melanocytic nevi (N = 41)
54
Solivetti et al., 1998 20 Pigmented skin lesions (N = 120) Yes (r = 0.93)
55
Hoffman et al., 1999 20 Melanomas (N = 264), benign Yes (r = 0.97)
pigmented lesions (N = 417)
28
Ulrich et al., 1999 7.5 and 20 Melanomas (N = 249) Yes (r = 0.76 and r = 0.94)
34
Lassau et al., 1999 20 Melanomas (N = 27) Yes (r > 0.95)
56
Lassau et al., 2002 20 Melanomas (N = 69) Yes (r > 0.96)
24
Serrone et al., 2002 20 Melanomas (N = 193) Yes (r = 0.95)
26
Pellacani et al., 2003 20 Melanomas (N = 40) Yes (r = 0.89)
37
Bessound et al., 2003 20 Pigmented skin lesions (N = 130) Yes (r > 0.96)
29
Lassau et al., 2006 12 or 13 Melanomas (N = 111) Yes (r > 0.93)
35
Gambichler et al., 2007 20 and 100 Melanomas (N = 13), Yes (r = 0.99) for both
melanocytic nevi (N = 37) frequencies
57
Guitera et al., 2008 75 Melanomas (N = 52), Yes (r = 0.91)
melanocytic nevi (N = 36)
30
Bobadilla et al., 2008 7–15 Basal cell carcinomas (N = 23) Yes (r = 0.90)
27
Machet et al., 2009 20 Melanomas (N = 31) Yes (moderate agreement
according to Bland and Altman)
31
Hayashi et al., 2009 15 or 30 Melanomas (N = 68) Yes (r = 0.89)
32
Vilana et al., 2009 10 Melanomas (N = 54) Yes (r = 0.93)
*Between the histological and ultrasound estimation of skin tumour thickness; N, number of studied tumours; r, Pearson’s correlation coefficient.

tool is usually available only at conventional ultrasound devices
(up to 18 MHz).
The diagnostics of pigmented skin lesions is a major clinical
part of the activity of a dermatologist who must always determine
the risk of malignant melanoma and adapt the treatment strategy.
When analysing the ultrasonographic shapes or echo signs, non-
significant differences were found between benign and malignant
skin tumours, and ultrasonography alone is not capable to identify
the final diagnosis. However, it can rather well define distinct cate-
gories of skin lesions – benign non-vascular or vascular tumours;
malignant tumours; inflammatory and infectious lesions; exoge-
nous skin components; and nail lesions.23 A large retrospective
study of 4338 ultrasonographic skin examinations showed that the
addition of ultrasonography increased the correctness of clinical
diagnosis from 73% to 97%.23 Overall sensitivity of ultrasonogra-
phy when diagnosing distinct categories of skin lesions can reach
99%, and specificity – 100%.23
Ultrasonographic morphology of melanomas and nevi show a
hypoechogenic, homogeneous and well-defined pattern, whereas
basal cell carcinomas are more heterogeneous with poorly defined
margins (Figs 2,3). Clinical and ultrasonographic measurements
can have good correlation in terms of the length and the width of
a tumour (r = 0.71 and r = 0.79, respectively).41 High-frequency
ultrasonographic measurements of the depth and regression of
basal cell carcinomas after photodynamic therapy potentially offer
a non-invasive guide to further treatment planning and follow-up
of such patients.42 Basal cell carcinomas can also show a mixed
echogenicity. When the tumours extend beyond the dermis–sub-
cutis border, the demarcation may become difficult because apart
from connective tissue septae, the subcutaneous fatty tissue is also
hypoechogenic. In addition, the deep tumour borders of basal cell
carcinomas cannot be visualized by 20 MHz. In these cases, ultra-
sonography with transducers of 13–15 MHz frequency may be
helpful.6
Other skin conditions
Other applications of high-frequency ultrasonography are skin
thickness measurement in inflammatory or fibrosing diseases such
as localized scleroderma, progressive systemic sclerosis, chronic
sclerodermiform graft-versus-host disease, psoriasis or lichen
planus. Ultrasonography with 20 MHz transducers helps to objec-
tify treatment response. Application of ultrasonography can also

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(a)
(b)
(c)
Figure 2 Nodular basal cell carcinoma. (a) Clinical image. (b)
Ultrasonic image of 14 MHz shows heterogeneous structure with
poorly defined margins, tumour thickness is 2.5 mm (A), tumour
width is 9.4 mm (B), E – epidermis, D – dermis. (c) Histological
image shows histological measurement of tumour thickness,
which is 2.8 mm (haematoxylin–eosin stain, original magnification
·20).
JEADV 2011, 25, 375–382 Journal of the European Academy of Dermatology and Venereology ª 2010 European Academy of Dermatology and Venereology
Jasaitiene et al.
(a)
(b)
Figure 3 Nodular melanoma. (a) Clinical image. (b) Ultrasonic
image of 14 MHz shows hypoechogenic, homogeneous and
well-defined structure, tumour thickness is 3.7 mm (A), tumour
width is 9.4 mm (B), E – epidermis, D – dermis.
be available for cosmetic-aesthetic purposes, e.g. evaluation of
actinic skin damage, localizing implants, and therapy control for
keloids and haemangiomas.2,3,43
Diseases with skin sclerosis on ultrasonographic evaluation usu-
ally present as a regular increase of dermis echogenicity as the
result of the accumulation of collagen fibres in this region and
increase of the skin thickness.44,45 Cosnes et al. using transducer of
13 MHz frequency in scleroderma plaque detected a characteristic
dense image resembling a flattened ‘yo-yo’ with undulations of the
dermis, disorganization, loss of thickness and thickened hypere-
chogenic bands in the subcutis.46
In general, echogenicity is decreased in dermal oedema, but
there are marked differences in the distribution of the low echo-
genic region in various diseases. In lipodermatosclerosis, a decrease
of echogenicity is noted mainly in the subepidermal region,
ª 2010 The Authors
Principles of high-frequency ultrasonography
whereas in lymphoedema and allergic reactions oedema spans the
entire dermis, and in cardiac failure echogenicity decreases in the
lower portion of the dermis.47
The ultrasonographic image of psoriatic plaque is characterized
by a varying increase in the width of the entry echo sign. Under
this echo, a hypoechogenic band related to inflammatory and vas-
cular changes is detectable. This band is more evident in the acute
stage. The dermis appears thicker and non-homogeneous. On
comparing ultrasonic images with histological examination, three
zones can be detected: A zone that represents the thickened stra-
tum corneum, B zone that represents the elongated rete ridges and
oedematous papillary dermis and C zone that represent the reticu-
lar dermis.48 The thickness of B zone of psoriatic plaque shows sig-
nificant correlation with the Psoriasis Area Severity Index score.48
A subepidermal low echogenic band (SLEB) was detected using
ultrasonography in photodamaged skin.49 There are data indicat-
ing that SLEB thickness correlates with the severity of photodam-
age and its measurement can be used for the evaluation of the
efficacy of anti-ageing preparations. The origin of SLEB is multi-
factorial. The main contributing factors are alternation in skin
fibre structure (collagen and elastin) and accumulation of glycosa-
minoglycans in the subepidermal region resulting in increased
water-binding capacity.49
In conclusion, ultrasonography is a versatile, painless, low-risk
and non-invasive procedure that can easily be performed and
repeated. It provides real-time visual information about benign
and malignant processes in the skin and subcutis. It could be
applied in the assessment of skin tumours, inflammatory or fibro-
sing skin diseases, monitoring of treatment results. Good or even
excellent correlation between ultrasonic and histological measure-
ments of melanomas thickness was obtained using transducers of
20, 75 or 100 MHz frequency, particularly in thinner primary
tumours. Whereas ultrasonic transducers of 7–15 MHz frequen-
cies for assessment of tumour thickness shows lower correlation
between ultrasonometric and histometric data, but has deeper
penetration and can provide better information about deep infil-
trating skin tumours. Even if some inaccuracy in ultrasonic mea-
surements comparing to histology has been shown, the
ultrasonographic preoperative assessment of tumour thickness can
be useful to predict the surgical planning of melanomas and to
choose the optimal treatment of basal cell carcinomas.
Acknowledgement
This work was partially sponsored by the Agency for Interna-
tional Science and Technology Development Programmes in
Lithuania under the Eurostars project SKINMONITOR ‘Diag-
nosis of Skin Cancer Based on Information and Communica-
tion Technologies Tools’.
References
1 Alexander H, Miller DL. Determining skin thickness with pulsed ultra-
sound. J Invest Dermatol 1979; 72: 17–19.
JEADV 2011, 25, 375–382 Journal of the European Academy of Dermatology and Venereology ª 2010 European Academy of Dermatology and Venereology
381
2 Hoffmann K, el Gammal S, Winkler K et al. Skin tumors in high-fre-
quency ultrasound. In Altmeyer P, el Gammal S, Hoffmann K, eds.
Ultrasound in Dermatology. Springer, New York, 1992: 181–201.
3 Korting HC, Gottlöber P, Schmid-Wendtner MH et al. Ultraschall
in der Dermatologie – Ein Atlas. Blackwell Verlag, Berlin, 1999:
37–99.
4 Rallan D, Harland CC. Ultrasound in dermatology – basic principles
and applications. Clin Exp Dermatol 2003; 28: 632–638.
5 Agache P, Humbert P. Measuring the Skin. Springer-Verlag, Berlin,
2004: 206–214.
6 Schmid-Wendtner MH, Burgdorf W. Ultrasound scanning in dermatol-
ogy. Arch Dermatol 2005; 141: 217–224.
7 Schmid-Wendtner MH, Dill-Müller D. Ultrasound technology in der-
matology. Semin Cutan Med Surg 2008; 27: 44–51.
8 Weichenthal M, Mohr P, Breitbart EW. The velocity of ultrasound in
human primary melanoma tissue-implications for the clinical use of
high resolution sonography. BMC Dermatol 2001; 1: 1.
9 Moore TL, Lunt M, McManus B et al. Seventeen-point dermal ultra-
sound scoring system-a reliable measure of skin thickness in patients
with systemic sclerosis. Rheumatology 2003; 42: 1559–1563.
10 De Rigal J, Escoffier C, Querleux B et al. Assessment of aging of the
human skin in vivo by ultrasonic imaging. J Invest Dermatol 1989; 93:
621–625.
11 Hoffmann K, Dirschka TP, Stucker M et al. Assessment of actinic skin
damage by 20 MHz sonography. Photodermatol Photoimmunol Photmed
1994; 10: 97–101.
12 Jemec GB, Gniadecka M, Ulrich J. Ultrasound in dermatology. Part I.
High frequency ultrasound. Eur J Dermatol 2000; 10: 492–497.
13 Lewandowski M, Nowicki A. High frequency coded imaging system
with RF software signal processing. IEEE Trans Ultrason Ferroelectr Freq
Control 2008; 55: 1878–1882.
14 Wilson T, Zagzebski J, Varghese T et al. The ultrasonix 500RP: a com-
mercial ultrasound research interface. IEEE Trans Ultrason Ferroelectr
Freq Control 2006; 53: 1772–1782.
15 Mari JM, Cachard C. Acquire real-time RF digital ultrasound data from
a commercial scanner. Electron J Tech Acoust 2007; 3: 1–16.
16 Despotovic I, Goossens B, Vansteenkiste E et al. Using phase informa-
tion in ultrasound RF-signals for tissue characterization. Annual work-
shop on Circuits, Systems and Signal Processing (ProRISC 2008), 19th,
Proceedings 2008; 314–317.
17 Rallan D, Dickson M, Bush NL et al. High-resolution ultrasound reflex
transmission imaging and digital photography: potential tools for the
quantitative assessment of pigmented lesions. Skin Res Technol 2006; 12:
50–59.
18 Raisutis R, Jasiuniene E, Jasaitiene D et al. Investigation of human skin
using pulse-echo ultrasonic technique: review and development. Ultra-
garsas (Ultrasound) 2010; 65: 37–41.
19 Yeh DT, Oralkan O, Ergun AS et al. High-frequency CMUT arrays for
high-resolution medical imaging. Proc SPIE Med Imaging 2005; 5750:
87–98.
20 Stefanidou D, D’Adamo P, Ronfani L et al. Detection of epidermal
thickening in GJB2 carriers with epidermal US. Radiology 2009; 251:
280–286.
21 Lassau N, Spatz A, Avril MF et al. Value of high-frequency US for
preoperative assessment of skin tumors. Radiographics 1997; 17: 1559–
1565.
22 Cammarota T, Pinto F, Magliaro A et al. Current uses of diagnostic
high-frequency ultrasound in dermatology. Eur J Radiol 1998; 27(Suppl.
2): S215–S223.
23 Wortsman X, Wortsman J. Clinical usefulness of variable-frequency
ultrasound in localized lesions of the skin. J Am Acad Dermatol 2010;
62: 247–256.
24 Serrone L, Solivetti FM, Thorel MF et al. High frequency ultrasound in
the preoperative staging of primary melanoma: a statistical analysis.
Melanoma Res 2002; 12: 287–290.
ª 2010 The Authors
382
25 Kaikaris V, Valiukevičien_e S, Rimdeika R et al. Sentinel lymph node
biopsy in melanoma patients: methods, indications, and clinical signifi-
cance. Medicina (Kaunas) 2003; 39: 621–630.
26 Pellacani G, Seidenari S. Preoperative melanoma thickness determina-
tion by 20-MHz sonography and digital videomicroscopy in combina-
tion. Arch Dermatol 2003; 139: 293–298.
27 Machet L, Belot V, Naouri M et al. Preoperative measurement of thick-
ness of cutaneous melanoma using high-resolution 20 MHz ultrasound
imaging: a monocenter prospective study and systematic review of the
literature. Ultrasound Med Biol 2009; 35: 1411–1420.
28 Ulrich J, Petereit S, Gollnick H. Preoperative sonographic diagnosis of
melanoma-comparison of 7,5-and 20-MHz sonography. Ultraschall Med
1999; 20: 197–200.
29 Lassau N, Lamuraglia M, Koscielny S et al. Prognostic value of angio-
genesis evaluated with high-frequency and colour Doppler sonography
for preoperative assessment of primary cutaneous melanomas: correla-
tion with recurrence after a 5 year follow-up period. Cancer Imaging
2006; 6: 24–29.
30 Bobadilla F, Wortsman X, Muñoz C et al. Pre-surgical high resolution
ultrasound of facial basal cell carcinoma: correlation with histology.
Cancer Imaging 2008; 8: 163–172.
31 Hayashi K, Koga H, Uhara H et al. High-frequency 30-MHz sonogra-
phy in preoperative assessment of tumor thickness of primary mela-
noma: usefulness in determination of surgical margin and indication
for sentinel lymph node biopsy. Int J Clin Oncol 2009; 14: 426–430.
32 Vilana R, Puig S, Sanchez M et al. Preoperative assessment of cutaneous
melanoma thickness using 10-MHz sonography. AJR Am J Roentgenol
2009; 193: 639–643.
33 Krahn G, Gottlober P, Sander C et al. Dermatoscopy and high fre-
quency sonography: two useful non-invasive methods to increase pre-
operative diagnostic accuracy in pigmented skin lesions. Pigment Cell
Res 1998; 11: 151–154.
34 Lassau N, Mercier S, Koscielny S et al. Prognostic value of high-
frequency sonography and color Doppler sonography for the preopera-
tive assessment of melanomas. AJR Am J Roentgenol 1999; 172: 457–461.
35 Gambichler T, Moussa G, Bahrenberg K et al. Preoperative ultrasonic
assessment of thin melanocytic skin lesions using a 100-MHz ultra-
sound transducer: a comparative study. Dermatol Surg 2007; 33: 818–
824.
36 Fornage BD, McGavran MH, Duvic M et al. Imaging of the skin with
20-MHz US. Radiology 1993; 189: 69–76.
37 Bessoud B, Lassau N, Koscielny S et al. High-frequency sonography and
color Doppler in the management of pigmented skin lesions. Ultrasound
Med Biol 2003; 29: 875–879.
38 Bland JM, Altman DG. Measuring agreement in method comparison
studies. Stat Methods Med Res 1999; 8: 135–160.
39 Tacke J, Haagen G, Hornstein OP et al. Clinical relevance of sonome-
try-derived tumour thickness in malignant melanoma – a statistical
analysis. Br J Dermatol 1995; 132: 209–214.
40 Srivastava A, Laidler P, Davies RP et al. The prognostic significance of
tumor vascularity in intermediate-thickness (0.76-4.0 mm thick) skin
melanoma. A quantitative histologic study. Am J Pathol 1988; 133: 419–
423.
JEADV 2011, 25, 375–382 Journal of the European Academy of Dermatology and Venereology ª 2010 European Academy of Dermatology and Venereology
Jasaitiene et al.
41 Desai TD, Desai AD, Horowitz DC et al. The use of high-frequency
ultrasound in the evaluation of superficial and nodular basal cell carci-
nomas. Dermatol Surg 2007; 33: 1220–1227. Discussion 1226–1227.
42 Moore JV, Allan E. Pulsed ultrasound measurements of depth and
regression of basal cell carcinomas after photodynamic therapy: rela-
tionship to probability of 1-year local control. Br J Dermatol 2003; 149:
1035–1040.
43 Eisenbeiß C, Welzel J, Eichler W et al. Influence of body water distribu-
tion on skin thickness: measurements using high-frequency ultrasound.
Br J Dermatol 2001; 144: 947–951.
44 Serup J. Localized scleroderma (Morphea): thickness of sclerotic plaques
as measured by 15-MHZ pulsed ultrasound. Acta Dermatol Venereol
(Stockh) 1984; 64: 214–219.
45 Szymanska E, Nowicki A, Mlosek K et al. Skin imaging with high fre-
quency ultrasound – preliminary results. Eur J Ultrasound 2000; 12:
9–16.
46 Cosnes A, Anglade MC, Revuz J et al. Thirteen megahertz ultrasound
probe: its role in diagnosing localized scleroderma. Br J Dermatol 2003;
148: 724–729.
47 Gniadecka M. Dermal oedema in lipodermatosclerosis: distribution,
effects of posture and compressive therapy evaluated by high-frequency
ultrasonography. Acta Derm Venereol 1995; 75: 120–124.
48 El-Zawahry MB, Abdel El-Hameed El-Cheweikh HM, Abd-El-Rahman
Ramadan S et al. Ultrasound biomicroscopy in the diagnosis of skin
diseases. Eur J Dermatol 2007; 17: 469–475.
49 Gniadecka M, Jemec GBE. Quantitative evaluation of chronological
aging and photoaging in vivo: studies on skin echogenicity and thick-
ness. Br J Dermatol 1989; 139: 815–821.
50 Reali UM, Santucci M, Paoli G et al. The use of high resolution ultra-
sound in preoperative evaluation of cutaneous malignant melanoma
thickness. Tumori 1989; 75: 452–455.
51 Gassenmaier G, Kiesewetter F, Schell H et al. Value of high resolution
ultrasound in determination of vertical tumor thickness in malignant
melanoma of the skin. Hautarzt 1990; 41: 360–364.
52 Hoffman K, Jung J, el Gemmal S et al. Malignant melanoma in
20-MHz B scan sonography. Dermatology 1992; 185: 49–55.
53 Partsch B, Binder M, Püspök-Schwarz M et al. Limitations of high
frequency ultrasound in determining the invasiveness of cutaneous
malignant melanoma. Melanoma Res 1996; 6: 395–398.
54 Solivetti FM, Thorel MF, Di Luca Sidozzi A et al. Role of high-defini-
tion and high frequency ultrasonography in determining tumor
thickness in cutaneous malignant melanoma. Radiol Med 1998; 96:
558–561.
55 Hoffmann K, Happe M, Schüller S et al. Ranking of 20 MHz sonogra-
phy of malignant melanoma and pigmented lesions in routine diagno-
sis. Ultraschall Med 1999; 20: 104–109.
56 Lassau N, Koscielny S, Avril MF et al. Prognostic value of angiogenesis
evaluated with high-frequency and color Doppler sonography for pre-
operative assessment of melanomas. AJR Am J Roentgenol 2002; 178:
1547–1551.
57 Guitera P, Li LX, Crotty K et al. Melanoma histological Breslow thick-
ness predicted by 75-MHz ultrasonography. Br J Dermatol 2008; 159:
364–369.
ª 2010 The Authors