Use of and beliefs about total body photography and dermatoscopy among US dermatology training programs: an update

Dermoscopy Use in Africa: Determinants and Challenges

INTRODUCTION

Dermoscopy has evolved over the years beyond distinguishing benign pigmented lesions from melanoma to diagnosing virtually all diseases in dermatology. Overwhelming evidence demonstrates its utility in improving diagnostic accuracy, reducing unnecessary biopsies and lesion monitoring. Dermoscopy is widely used in Western nations, hence most descriptions of lesions in literature are predominantly on Fitzpatrick skin types I-III. Current evidence shows that there are unique dermoscopic features in the dark skin as a result of pigment and pathological reactions. Nationwide surveys and reports have been conducted across several continents to highlight prevalence and factors influencing dermoscopy use with the hope of maximizing its apparent benefits. There are currently no such reports from Africa.

OBJECTIVES

To evaluate dermoscopy use and its determinants among dermatologists in Africa.

METHODS

A cross-sectional study. Online forms were e-mailed to individual practicing dermatologists and members of the African Society of Dermatologists and Venereologists.

RESULTS

There were 196 respondents from 24 African countries. Half of them used dermoscopy. Training, practice settings and location, provision of dermatoscopes by institutions and knowledge of criteria were notable significant determinants. Multiple training exposures, knowledge of criteria, availability of dermatoscopes, use of both hand-held and videodermatoscopes, average number of patients seen per day, and a positive outlook towards dermoscopy were significant determinants of frequency of use. Leading impediments were lack of training and inadequate dermatoscopes in practice.

CONCLUSIONS

Dermoscopy use in Africa is relatively low. Incorporating dermoscopy training into the curriculum with provision of dermatoscopes by training institutions will promote wider usage.

Training dermatology residents in dermatoscopy: A case control lecture series assessment

Lack of standardized dermatoscopy training limits confidence and accuracy. We assessed the effect of a dermatoscopy lecture series on the diagnostic accuracy of dermatology residents' biopsies. Additionally, we evaluated resident comfort with and knowledge of dermatoscopy before and after the curriculum. Twelve dermatology residents were enrolled in a 5-month dedicated dermatoscopy curriculum. To assess knowledge of and comfort with dermatoscopy, residents were given a 50-question assessment and 21-question survey before and after the curriculum. Change in diagnostic accuracy was assessed by comparing the suspected clinical diagnosis to the final histopathologic diagnosis of lesions biopsied by residents before and after the course. Upon completion of the curriculum, residents felt significantly more comfortable performing dermatoscopy (P = .002) and using dermatoscopy to identify melanocytic nevi (P = .037) and melanomas (invasive and in situ) (P = .012). Postgraduate year 2 residents also showed significantly improved diagnostic accuracy after the training course (odds ratio, 1.33; 95% confidence interval, 1.06-1.67; P = .013). Our study was limited by a small sample size of 12 residents from a single academic institution. A formal dermatoscopy course can effectively improve dermatology residents' knowledge, confidence, and diagnostic accuracy when using dermatoscopy.

Melanoma: How and When to Consider Clinical Diagnostic Technologies

In response to rising rates of melanoma worldwide, novel non-invasive melanoma detection techniques are emerging to facilitate the early detection of melanoma and decrease unnecessary biopsies of benign pigmented lesions. Because they often report similar study findings, it may be difficult to determine how best to incorporate these technologies into clinical practice based on their supporting studies alone. As an expansion of the recent article by Fried et al.¹, which reviewed the clinical data supporting these non-invasive melanoma detection techniques, the first article in this continuing medical education series provides practical advice on how and when to use various non-invasive melanoma detection techniques into clinical practice.

Dermoscopy Proficiency Expectations for US Dermatology Resident Physicians: Results of a Modified Delphi Survey of Pigmented Lesion Experts

Importance

Dermoscopy education in US dermatology residency programs varies widely, and there is currently no existing expert consensus identifying what is most important for resident physicians to know.

Objectives

To identify consensus-based learning constructs representing an appropriate foundational proficiency in dermoscopic image interpretation for dermatology resident physicians, including dermoscopic diagnoses, associated features, and representative teaching images. Defining these foundational proficiency learning constructs will facilitate further skill development in dermoscopic image interpretation to help residents achieve clinical proficiency.

Design, Setting, and Participants

A 2-phase modified Delphi surveying technique was used to identify resident learning constructs in 3 sequential sets of surveys-diagnoses, features, and images. Expert panelists were recruited through an email distributed to the 32 members of the Pigmented Lesion Subcommittee of the Melanoma Prevention Working Group. Twenty-six (81%) opted to participate. Surveys were distributed using RedCAP software.

Main Outcomes and Measures

Consensus on diagnoses, associated dermoscopic features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for US dermatology resident physicians.

Results

Twenty-six pigmented lesion and dermoscopy specialists completed 8 rounds of surveys, with 100% (26/26) response rate in all rounds. A final list of 32 diagnoses and 116 associated dermoscopic features was generated. Three hundred seventy-eight representative teaching images reached consensus with panelists.

Conclusions and Relevance

Consensus achieved in this modified Delphi process identified common dermoscopic diagnoses, associated features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for dermatology residency training. This list of validated objectives provides a consensus-based foundation of key learning points in dermoscopy to help resident physicians achieve clinical proficiency in dermoscopic image interpretation.

Clinical Photography in Dermatology: Perception and Behavior of Dermatologists - A Pilot Study

Background and Aims:

Clinical photography is a vital component of patient care in dermatology. Casual sharing of images over social media is a common practice among the clinicians. We performed this study to assess the perception and behavior of dermatologists toward clinical photography.

Materials and Methods:

A questionnaire having 10 questions was prepared using an online survey platform and the link to it was shared in a dermatologists group using the WhatsApp application. Among questions, nine were multiple choice type while the tenth was open ended. Some of the questions allowed multiple responses and answering all the questions was not mandatory. Resultant data was analyzed using Chi-square test for categorical variables and unpaired t-test to compare quantitative variables.

Results:

A total of 119 dermatologists participated in the study. Most respondents used personal smartphone (72.9%, 86/118) for imaging followed by digital camera (27.9%, 33/118). Monitoring the disease process (83.9%, 99/118) and research publications (51.6%, 61/118) were the commonest reasons for photography. Except one all participants had shared images and most commonly in professional WhatsApp groups (86.3%, 101/117) and to personal WhatsApp number (31.6%, 37/117). Patient consent for photography was duly recorded by very few (14.4%, 17/118). More than half (52.3%, 56/107) responded monitoring of the disease as the single most important application of clinical photography in dermatology.

Conclusion:

Adequate awareness regarding appropriate usage and safekeeping of gadget meant for imaging and necessity of obtaining written consent for taking as well as sharing the images and secure storage of the images was found to be lacking.

Establishing the use of total body photography among U.K. dermatologists

Total body photography (TBP) is increasingly used to monitor skin lesions in individuals at high risk of melanoma. Two surveys of U.S. dermatologists demonstrated variable reasons for use and conflicting beliefs regarding TBP efficacy. Although TBP may reduce number-needed-to-biopsy when diagnosing melanoma, there is scarce evidence for TBP use in lower-risk populations and a lack of consensus on optimal TBP use. Thus, we undertook the first U.K. survey to assess TBP rationale, target populations, and protocols.

Diagnostic tools used for melanoma: A survey of Australian general practitioners and dermatologists

BACKGROUND/OBJECTIVE

Diagnostic tools such as dermoscopy, sequential digital dermoscopy imaging (SDDI), total body photography (TBP) and automated diagnostic tools are available to assist in early melanoma diagnosis. The use, accessibility and barriers of dermoscopy have been well studied; however, there are few similar studies regarding SDDI, TBP and automated diagnostic tools. We aim to understand the use of these diagnostic aids amongst Australian general practitioners (GPs) and dermatologists.

METHODS

Between June 2019 and January 2020, GPs and dermatologists across Australia were invited to participate in an online survey. Surveys were distributed through GP and dermatology organisations.

RESULTS

A total of 227 survey responses were received, 175 from GPs and 52 from dermatologists. Amongst GPs, 44.6% worked in a skin cancer clinic. Dermoscopy was used at least occasionally by 98.9% of all GPs. SDDI was used by 93.6% of skin cancer GPs, 80.8% of dermatologists and 45.3% of generalist GPs. TBP was used or recommended by 77.1% of generalist GPs, 82.3% of skin cancer GPs and 86.5% of dermatologists. The most common barriers to the use of TBP were cost, limited accessibility, poor patient compliance, and time required for both patients and doctors. Very few clinicians reported using automated diagnostic tools. There was an interest in future diagnostic aids for melanoma in 88% of GPs and dermatologists.

CONCLUSION

Dermoscopy, SDDI and TBP were commonly used by responding Australian skin cancer GPs and dermatologists in this survey. Automated diagnostic tools were not reported to be used routinely. Several barriers were identified for use of TBP.

The role of technology in melanoma screening and diagnosis

Melanoma presents challenges for timely and accurate diagnosis. Expert panels have issued risk-based screening guidelines, with recommended screening by visual inspection. To assess how recent technology can impact the risk/benefit considerations for melanoma screening, we comprehensively reviewed non-invasive visual-based technologies. Dermoscopy increases lesional diagnostic accuracy for both dermatologists and primary care providers; total body photography and sequential digital dermoscopic imaging also increase diagnostic accuracy, are supported by automated lesion detection and tracking, and may be best suited to use by dermatologists for longitudinal follow-up. Specialized imaging modalities using non-visible light technology have unproven benefit over dermoscopy and can be limited by cost, access, and training requirements. Mobile apps facilitate image capture and lesion tracking. Teledermatology has good concordance with face-to-face consultation and increases access, with increased accuracy using dermoscopy. Deep learning models can surpass dermatologist accuracy, but their clinical utility has yet to be demonstrated. Technology-aided diagnosis may change the calculus of screening; however, well-designed prospective trials are needed to assess the efficacy of these different technologies, alone and in combination to support refinement of guidelines for melanoma screening.

Reliable test of clinicians' mastery in skin cancer diagnostics

Differentiating between benign and malignant skin lesions can be very difficult and should only be done by sufficiently trained and skilled clinicians. To our knowledge there are no validated tests for reliable assessments of clinicians' ability to perform skin cancer diagnostics. To develop and gather validity evidence for a test in skin cancer diagnostics, a multiple-choice questionnaire (MCQ) was developed based on informal interviews with seven content experts from five skin cancer centers in Denmark. Validity evidence for the test was gathered from May until July 2019 using Messick's validity framework (content, response process, internal structure, relationship to other variables and consequences). Item content was revised through a Delphi-like review process and then piloted on 36 medical students and 136 doctors using a standardized response process. Results enabled an analysis of the internal structure and relationship to other variables of the test. Finally, the contrasting groups method was used to investigate the test's consequences (pass-fail standard). The initial 90-item MCQ was reduced to 40 items during the Delphi-like review process. Item analysis revealed that 25 of the 40 selected items were level I-III quality items with a high internal consistency (Cronbach's α = 0.83) and highly significant (P ≤ 0.0001) differences in test scores between participants with different occupations or levels of experience. A pass-fail standard of 12 (48%) correct answers was established using the contrasting groups' method. The skin cancer diagnostics MCQ developed in this study can be used for reliable assessments of clinicians' competencies.

Dermoscopy in China: current status and future prospective

OBJECTIVE

Dermoscopy is a useful technique for improving the diagnostic accuracy of various types of skin disorders. In China, dermoscopy has been widely accepted, and domestic researchers have made tremendous progress in the field of dermoscopy. The main purpose of this review is to summarize the current status of dermoscopy in China and identify its future directions.

DATA SOURCES

Articles included in this review were obtained by searching the following databases: Wanfang, China National Knowledge Infrastructure, PubMed, and the Web of Science. We focused on research published before 2019 with keywords including dermoscopy, dermoscopic, dermoscope and trichoscopy.

STUDY SELECTION

A total of 50 studies were selected. Of these studies, 20 studies were in Chinese and 30 in English, research samples of all the studies were collected from Chinese populations.

RESULTS

Since 2000, more than 380 articles about dermoscopy have been published in domestic or foreign journals. Dermoscopy can improve the diagnostic accuracy of neoplastic diseases, evaluating the therapeutic effect of treatment, and determining the treatment endpoint, and it can also assist in the differential diagnosis of inflammatory diseases and in the assessment of the severity of the disease. In addition, researches about the applications of dermoscopy during surgical treatment have been published. Training courses aiming to improve the diagnostic ability of dermatologists, either face-to-face or online, have been offered. The Chinese Skin Image Database, launched in 2017 as a work platform for dermatologists, has promoted the development of dermoscopy in China. Computer-aided diagnostic systems based on the Chinese population are ready for use. In the future, cooperation, resource sharing, talent development, image management, and computer-aided diagnosis will be important directions for the development of dermoscopy in China.

CONCLUSION

Dermoscopy has been widely used and developed in China, however, it still needs to address more challenges in the future.

Dermascope Use by Osteopathic Primary Care Physicians

CONTEXT

Osteopathic physicians (ie, DOs) in primary care may play a critical role in the early detection of skin cancer. Dermoscopy improves diagnostic accuracy; however, its use among primary care DOs remains understudied.

OBJECTIVES

To document dermascope use among DOs in primary care, to examine physician and practice characteristics associated with having used and having heard of a dermascope, and to examine the barriers to dermascope use.

METHODS

Osteopathic physicians were recruited to complete an anonymous survey assessing demographic factors, physician and practice characteristics, confidence in differentiating skin lesions, knowledge and dermascope use, and barriers to dermascope use. Bivariate analyses were conducted, and the significant factors were entered into 2 separate logistic regressions.

RESULTS

A total of 768 participants were included in the study. Four hundred ten (54%) had heard of a dermascope, and 123 (15%) had used one. The statistically significant multivariate predictors for having used a dermascope (model 1) were graduating from medical school after 1989 and having greater confidence in differentiating skin lesions (OR, 2.2; 95% CI, 1.66-2.79). Those who graduated after 2009 were 9.5 times more likely and those graduating between 2000 and 2009 were 4.3 times more likely to have used a dermascope than those graduating before 1990 (95% CI, 4.29-20.90 and 95% CI, 2.04-9.23, respectively). Ever having heard of a dermascope (model 2) was associated with being female (OR, 1.4; 95% CI, 1.02-1.87); practicing in a group (OR, 1.6; 95% CI, 1.05-2.36), academic (OR, 2.2; 95% CI, 1.26-3.86), or community center (OR, 2.2; 95% CI, 1.20-4.00); and having greater confidence in differentiating skin lesions (OR, 1.3; 95% CI, 1.15-1.55). Both models were statistically significant and correctly classified 605 (84.1%) (model 1) and 444 (58.4%) participants (model 2).

CONCLUSION

Dermascope use could help primary care DOs improve their diagnostic accuracy for skin cancer and reduce unnecessary referrals to specialists. Efforts to disseminate knowledge about the benefits of using a dermascope to primary care DOs are needed.

Examining the factors associated with past and present dermoscopy use among family physicians

Introduction

Family physicians (FPs) play a critical role in the early detection of skin cancers. Dermoscopy can improve diagnostic accuracy but its use by FPs in the United States (US) remains understudied.

Objectives

To examine dermoscopy use, factors associated with ever having used (Model 1) and currently using the dermascope (Model 2), and barriers.

Methods

We recruited 705 practicing FPs in-person at conferences and on-line to complete an anonymous, 46 item survey measuring: demographic factors, physician and practice characteristics; confidence in differentiating skin lesions; knowledge and use of dermoscopy; intentions to use; and barriers to use. We conducted bivariate analysis for each outcome and entered the significant predictors into two logistic regressions.

Results

Almost 20% had ever used a dermascope and 8.3% were currently using it. Ever having used a dermascope was associated with being 39 years of age or younger, practicing in academia or community centers, and having higher confidence differentiating skin lesions. Current use was associated with seeing more than 400 patients per month and being 60 years-of-age or older.

Conclusion

Use of dermoscopy by FPs is low. This study is an initial step in understanding its use among US FPs.

Mole Mapping for Management of Pigmented Skin Lesions

Identifying new or changing melanocytic lesions, particularly in patients with numerous or atypical nevi, can be challenging. Total-body photography and sequential digital dermoscopy imaging, together known as digital follow-up, are 2 prominent forms of noninvasive imaging technology used in mole mapping that have been found to improve diagnostic accuracy, detect earlier-stage melanomas, and reduce costs. Digital follow-up, in combination with direct-to-consumer applications and teledermatology, is already revolutionizing the ways in which physicians and patients participate in melanoma surveillance and will likely continue to enhance early detection efforts.

Enhancing Skin Cancer Diagnosis with Dermoscopy

Dermoscopy increases the sensitivity for skin cancer detection, decreases the number of benign lesions biopsied for each malignant diagnosis, and enables the diagnosis of thinner melanomas compared with naked eye examination. Multiple meta-analyses have identified that dermoscopy improves the diagnostic accuracy for melanoma when compared with naked eye examination. In addition, studies have established that dermoscopy can aid in the detection of keratinocyte carcinomas. Dermoscopy triage algorithms have been developed to help novices decide when a biopsy or a referral is most appropriate. In this article, the authors illustrate the dermoscopic features that assist in identifying melanoma and keratinocyte carcinomas.

Analysis of dermoscopy teaching modalities in United States dermatology residency programs

The use of dermoscopy in dermatology residency programs is on the rise (over 94% of chief residents reported using a dermatoscope in 2013) [1]. Despite increased use (100% of our surveyed residents reported using a dermatoscope), dermoscopy training is one of the aspects of United States dermatology residency training with the lowest resident satisfaction [2]. Diagnostic accuracy with dermoscopy is highly correlated with the amount of dermoscopy training the user has undertaken [3]. We sought to analyze dermoscopy use in US Dermatology residencies to better understand resident dermoscopy utilization and teaching modalities. We found residents learn dermoscopy via multiple teaching modalities. The most commonly reported dermoscopy teaching modality was didactic lectures, followed by time in clinic with a dermoscopy expert. Of the different teaching modalities, time in the clinic with a dermoscopy expert was reported to be the most effective. We also found that the majority of dermatology residents receive didactic dermoscopy lectures and clinical dermoscopy training on the differentiation of benign nevi from melanoma using dermoscopy, the detection of basal cell carcinoma, and the identification of seborrheic keratosis. However, few residents receive dedicated training on the use of dermoscopy in the evaluation of inflammatory dermatoses and skin infections despite dermoscopy's demonstrated value in both areas [4-7].

Use of and intentions to use dermoscopy among physicians in the United States

Background

Dermatologists routinely use dermoscopy to improve diagnostic accuracy of skin cancers. Much less is known about its use among other physicians who routinely examine the skin, such as family physicians, internists and plastic surgeons.

Objectives

To document the use of dermoscopy in a sample of US physicians and to examine physician and practice characteristics associated with ever having used a dermascope and having some intentions to incorporate dermoscopy into clinical practice during the next 12 months.

Methods

From September 2015 to February 2016, we recruited 1,466 practicing physicians in person and online to complete an anonymous survey that assessed: demographic factors; physicians and practice characteristics; confidence differentiating skin lesions; knowledge and use of dermoscopy; and intentions and barriers to use dermoscopy. We conducted bivariate analysis to examine the relationship between key factors and the outcomes and entered the significant predictors into two separate logistic regressions.

Results

Fifteen percent of participants had ever used a dermascope and 6% were currently using it. Factors significantly associated with ever having used a dermascope (Model 1) and having intentions to use (Model 2) at the multivariate level were: recent graduation from medical school (strongest predictor in both models), identifying as a family physician, seeing a higher number of patients with skin cancer and having a higher level of confidence differentiating skin lesions. Both models were highly significant.

Conclusion

Use of dermoscopy was low. Promotional efforts to increase dermoscopy use in the US are needed.

Triage amalgamated dermoscopic algorithm (TADA) for skin cancer screening

Importance

Dermoscopic triage algorithms have been shown to improve beginners’ abilities for identifying pigmented skin lesions requiring biopsy.

Objective

To estimate the diagnostic accuracy of the Triage Amalgamated Dermoscopic Algorithm (TADA) for pigmented and nonpigmented skin cancers. Secondarily, to compare TADAs performance to those of existing triage algorithms for the identification of pigmented skin cancers.

Design

Cross-sectional, observational, reader study that took place at a beginner and intermediate level dermoscopy course.

Participants

Two hundred medical professionals of various specialties attended the course and 120 voluntarily joined the study (60% participation rate).

Exposures

After receiving basic dermoscopy training, participants evaluated 50 polarized, dermoscopic images of pigmented (22 benign, 18 malignant) and nonpigmented (1 benign, 9 malignant) skin lesions using TADA. Pigmented lesions were also evaluated using the Three-Point Checklist and AC Rule. With TADA, participants first determined if a lesion was an unequivocal angioma, dermatofibroma, or seborrheic keratosis, which would exclude it from further evaluation. All other lesions were assessed for architectural disorder, starburst pattern, blue-black or gray color, shiny white structures, negative network, ulcer/erosion, or vessels. Any one feature indicated suspicion for malignancy.

Results

Most participants were dermatologists (n=64, 53.3%) or primary care physicians (n=41, 34.2%), and many lacked previous dermoscopy training (n=52, 43.3%). TADA’s sensitivity and specificity for all skin cancers was 94.6% (95% CI=93.4–95.7%) and 72.5% (95% CI=70.1–74.7%), respectively. For pigmented skin cancers, the sensitivity and specificity were 94.0% (95% CI=92.9–95.0%) and 75.5% (95% CI=73.8–77.2%). This compared to 71.9% (95%CI=69.8–73.9%) and 81.4% (95%CI=79.7–83.0%) for the Three-Point Checklist and 88.6% (95%CI=87.1–89.9%) and 78.7% (95%CI=76.9–80.3%) for the AC Rule.

Conclusions

These results suggest that TADA compares favorably to existing triage algorithms and might be a useful triage tool with high sensitivity and specificity for pigmented and nonpigmented skin cancers. Further studies are needed to validate these preliminary observations.

The need for improved dermoscopy training in residency: a survey of US dermatology residents and program directors

Background

Inadequate dermoscopy training represents a major barrier to proper dermoscopy use.

Objective

To better understand the status of dermoscopy training in US residency programs.

Methods

A survey was sent to 417 dermatology residents and 118 program directors of dermatology residency programs.

Results

Comparing different training times for the same training type, residents with 1–10 hours of dedicated training had similar confidence using dermoscopy in general (p = 1.000) and satisfaction with training (p = .3224) than residents with >10 hours of dedicated training. Comparing similar training times for different training types, residents with 1–10 hours of dedicated training had significantly increased confidence using dermoscopy in general (p = .0105) and satisfaction with training (p = .0066) than residents with 1–10 hours of only bedside training. Lastly, residents with 1–10 hours of dedicated training and >10 hours of dedicated training had significantly increased confidence using dermoscopy in general (p = .0002, p = .2471) and satisfaction with training (p <.0001, p < .0001) than residents with no dermoscopy training at all.

Conclusions

Dermoscopy training in residency should include formal dermoscopy training that is overseen by the program director and is possibly supplemented by outside dermoscopy training.

Variation in the Cost of Managing Actinic Keratosis

Importance

Actinic keratosis (AK), a skin growth induced by ultraviolet light exposure, requires chronic management because a small proportion can progress into squamous cell skin cancer. Spending for AK management was more than $1 billion in 2004. Investigating geographic variation in AK spending presents an opportunity to decrease waste or recoup excess spending.

Objective

To evaluate geographic variation in health care cost for management of AKs and the association with patient-related and health-related factors.

Design, Setting, and Participants

This retrospective cohort study was performed using data from the MarketScan medical claims database of 488 324 continuously enrolled members with 2 or more claims for AK. Data from January 1, 2008, to December 31, 2012, was used.

Main Outcomes and Measures

Annual costs of care were calculated for outpatient visits, AK destruction, and medications for AKs, and the total of these components. Costs were adjusted for inflation to 2014 US dollars. To display cost variation, we calculated the ratio of mean cost in the highest quintile (Q5) relative to the mean in the lowest quintile (Q1), or the Q5:Q1 ratio; Q5:Q1 ratios were adjusted based on age, sex, history of nonmelanoma skin cancer, US geographic region, and population density (metropolitan statistical area).

Results

Overall, data from 488 324 continuously enrolled members (mean [SD] age, 53.1 [7.5] years; 243 662 women) with 2 or more claims for AK were included. Overall, patients had 1 085 985 claims related to AK, and dermatologists accounted for 71.0% of claims. The 2-year total cost was $111.5 million, with $52.4 million in 2011 and $59.1 million in 2012. The unadjusted Q5:Q1 ratios for total annual cost per patient ranged from 9.49 to 15.10. Adjusted ratios ranged from 1.72 to 1.80.

Conclusions and Relevance

There is variation in AK management cost within and between regions. This is not fully explained by differences in patient characteristics such as age, sex, or comorbidities. The annual cost for 10 common conditions from Medicare had lower Q5:Q1 ratios that ranged from 1.33 (joint degeneration of back/neck) to 1.69 (chronic sinusitis) when compared with 1.72 to 1.80 for AKs. This suggests an opportunity to investigate and improve the value of health care delivery in the management of AKs.

Factors driving the use of dermoscopy in Europe: a pan-European survey

BACKGROUND

When used correctly, dermoscopy is an essential tool for helping clinicians in the diagnosis of skin diseases and the early detection of skin cancers. Despite its proven benefits, there is a lack of data about how European dermatologists use dermoscopy in everyday practice.

OBJECTIVES

To identify the motivations, obstacles and modifiable factors influencing the use of dermoscopy in daily dermatology practice across Europe.

METHODS

All registered dermatologists in 32 European countries were invited to complete an online survey of 20 questions regarding demographic and practice characteristics, dermoscopy training and self-confidence in dermoscopic skills, patterns of dermoscopy use, reasons for not using dermoscopy and attitudes relating to dermoscopy utility.

RESULTS

We collected 7480 valid answers, of which 89% reported use of dermoscopy. The main reasons for not using dermoscopy were lack of equipment (58% of nonusers) and lack of training (42%). Dermoscopy training during residency was reported by 41% of dermoscopy users and by 12% of nonusers (P < 0·001). Dermatologists working in public hospitals were the least likely to use dermoscopy. High use of dermoscopy across the spectrum of skin diseases was reported by 62% of dermoscopy users and was associated with dermoscopy training during residency, the use of polarized light and digital dermoscopy devices, longer dermoscopy practice, younger age and female gender.

CONCLUSIONS

Expanding access to dermoscopy equipment, especially in public healthcare facilities and establishing dermoscopy training during dermatology residency would further enhance the substantially high dermoscopy use across European countries.

Practice Gaps in Dermatology: Melanocytic Lesions and Melanoma

Early detection remains the most important strategy to reduce melanoma mortality. The identification and evaluation of new or changing skin lesions are important components of melanoma screening and are best performed today using complementary noninvasive imaging technologies, such as total body photography (TBP), dermoscopy, sequential digital dermoscopic imaging (SDDI), and reflectance confocal microscopy (RCM). Despite strong evidence showing that these screening techniques improve diagnostic accuracy for melanoma, they are not widely used by dermatologists. In this practice gaps review, the authors highlight the use, evidence, and rationale for TBP, dermoscopy, SDDI, and RCM.

Dermoscopy, a useful tool for general practitioners in melanoma screening: a nationwide survey

BACKGROUND

Dermoscopy improves diagnostic accuracy in melanoma, as shown by several meta-analyses. Although it is used by general practitioners (GPs) in Australia, Canada and Italy, no published data on this topic are available in France.

OBJECTIVES

To review the opinions and use of dermoscopy by GPs in France and to understand their practice of skin examination.

METHODS

We designed a descriptive and cross-sectional survey and conducted it between 26 November and 26 December 2014. An anonymous, multiple-choice questionnaire about the demographic characteristics, skin examination modalities and use and training in dermoscopy was sent to 4057 GPs in four large regions of France. Pearson, χ(2) , Student, Welch and Fisher tests were used for cross-tabulation statistical analysis.

RESULTS

Only 8% of respondents had access to a dermoscope; most were male practitioners and aged > 50 years. Dermoscopy increased self-confidence in analysing pigmented lesions (P = 0·004), and dermoscopy users referred fewer patients to dermatologists. The number of biopsies was reduced in the dermoscopy users group (P = 0·004). In total, 425 questionnaires were returned and analysed. Dermoscopy users took more time to evaluate a single pigmented lesion (P = 0·015). Only 16·9% of physicians declared having received some training on dermoscopy, yet this number reached 47% for those owning a dermoscope. Their training was mostly short and recent. Overall 29·2% of the respondents said the main advantage was to reduce the number of referrals to the dermatologists (P = 0·004), while its main disadvantage was the necessity of training (54·6%). Our responders declared they could spend seven working days on a dermoscopy training course.

CONCLUSIONS

Our study demonstrates positive opinions regarding dermoscopy, despite a minority of French GPs using this technique in the areas surveyed. The need for formal training appears to be the main limitation to wider use. Appropriate and specifically designed training programmes should be offered.

Total body photography for skin cancer screening

BACKGROUND

Total body photography may aid in melanoma screening but is not widely applied due to time and cost. We hypothesized that a near-simultaneous automated skin photo-acquisition system would be acceptable to patients and could rapidly obtain total body images that enable visualization of pigmented skin lesions.

METHODS

From February to May 2009, a study of 20 volunteers was performed at the University of Virginia to test a prototype 16-camera imaging booth built by the research team and to guide development of special purpose software. For each participant, images were obtained before and after marking 10 lesions (five "easy" and five "difficult"), and images were evaluated to estimate visualization rates. Imaging logistical challenges were scored by the operator, and participant opinion was assessed by questionnaire.

RESULTS

Average time for image capture was three minutes (range 2-5). All 55 "easy" lesions were visualized (sensitivity 100%, 90% CI 95-100%), and 54/55 "difficult" lesions were visualized (sensitivity 98%, 90% CI 92-100%). Operators and patients graded the imaging process favorably, with challenges identified regarding lighting and positioning.

CONCLUSIONS

Rapid-acquisition automated skin photography is feasible with a low-cost system, with excellent lesion visualization and participant acceptance. These data provide a basis for employing this method in clinical melanoma screening.

Clinical performance of the Nevisense system in cutaneous melanoma detection: an international, multicentre, prospective and blinded clinical trial on efficacy and safety

BACKGROUND

Even though progress has been made, the detection of melanoma still poses a challenge. In light of this situation, the Nevisense electrical impedance spectroscopy (EIS) system (SciBase AB, Stockholm, Sweden) was designed and shown to have the potential to be used as an adjunct diagnostic tool for melanoma detection.

OBJECTIVES

To assess the effectiveness and safety of the Nevisense system in the distinction of benign lesions of the skin from melanoma with electrical impedance spectroscopy.

METHODS

This multicentre, prospective, and blinded clinical study was conducted at five American and 17 European investigational sites. All eligible skin lesions in the study were examined with the EIS-based Nevisense system, photographed, removed by excisional biopsy and subjected to histopathological evaluation. A postprocedure clinical follow-up was conducted at 7 ± 3 days from the initial measurement. A total of 1951 patients with 2416 lesions were enrolled into the study; 1943 lesions were eligible and evaluable for the primary efficacy end point, including 265 melanomas - 112 in situ and 153 invasive melanomas with a median Breslow thickness of 0·57 mm [48 basal cell carcinomas (BCCs) and seven squamous cell carcinomas (SCCs)].

RESULTS

The observed sensitivity of Nevisense was 96·6% (256 of 265 melanomas) with an exact one-sided 95% lower confidence bound estimated at 94·2% and an observed specificity of 34·4%, and an exact two-sided 95% confidence bound estimated at 32·0-36·9%. The positive and negative predictive values of Nevisense were 21·1% and 98·2%, respectively. The observed sensitivity for nonmelanoma skin cancer was 100% (55 of 48 BCCs and seven SCCs) with an exact two-sided 95% confidence bound estimated at 93·5-100·0%.

CONCLUSIONS

Nevisense is an accurate and safe device to support clinicians in the detection of cutaneous melanoma.

Dermatoscopy for melanoma and pigmented lesions

This article presents an overview of the history and development of dermatoscopy over the last 2 decades. The common dermatoscopic diagnostic algorithms are discussed, including classic pattern analysis, the ABCD rule (asymmetry, border, color, and dermatoscopic structures), 7-point checklist, and Menzies method, as well as a new method by the authors (ASAP: a simple and practical approach). In addition, evidence on the clinical impact and challenges of dermatoscopy for the diagnosis and management of pigmented lesions and the importance of training are reviewed.

Ethical considerations in dermatologic photography

In dermatology, clinical photographs are an essential component of patient care, enabling clinicians to document changes in skin pathology over time. Recent advances in digital technology and the electronic medical record have revolutionized clinical photography; however, these advances bring with them new ethical, legal, and social concerns. Photographs, more than other forms of documentation, have the potential to make patients uncomfortable. The act of photography, especially for those images requiring exposure of the genital area or the entire body, can be an uncomfortable experience for patients, necessitating the clinician and photographer to take an empathic stance in this setting. The Internet has elicited an increasing, and a very real, concern for patients about possible distribution and use of images outside of their individual care. The clinician and staff can allay these fears by professionally and empathetically addressing their concerns. In addition, it is important that patients receive appropriate informed consent about clinical photographs and the potential use of the images in their care, education, and research. Given the multitude of methods for recording clinical photographs, combined with the increasing complexity of image storage, standardization becomes a critical tool in providing consistency among images and achieving more equitable and efficacious care. To achieve this goal and improve the baseline standard of continuity of care for dermatological practices, we review the role of photographs, develop a model for patient consent, and establish standards for photography so as to provide the most ethical care for the patient.