The impact of dermoscopy on the management of pigmented lesions in everyday clinical practice of general dermatologists: a prospective study

Improving Skin Cancer Diagnostics Through a Mobile App With a Large Interactive Image Repository: Randomized Controlled Trial

BACKGROUND

Skin cancer diagnostics is challenging, and mastery requires extended periods of dedicated practice.

OBJECTIVE

The aim of the study was to determine if self-paced pattern recognition training in skin cancer diagnostics with clinical and dermoscopic images of skin lesions using a large-scale interactive image repository (LIIR) with patient cases improves primary care physicians' (PCPs') diagnostic skills and confidence.

METHODS

A total of 115 PCPs were randomized (allocation ratio 3:1) to receive or not receive self-paced pattern recognition training in skin cancer diagnostics using an LIIR with patient cases through a quiz-based smartphone app during an 8-day period. The participants' ability to diagnose skin cancer was evaluated using a 12-item multiple-choice questionnaire prior to and 8 days after the educational intervention period. Their thoughts on the use of dermoscopy were assessed using a study-specific questionnaire. A learning curve was calculated through the analysis of data from the mobile app.

RESULTS

On average, participants in the intervention group spent 2 hours 26 minutes quizzing digital patient cases and 41 minutes reading the educational material. They had an average preintervention multiple choice questionnaire score of 52.0% of correct answers, which increased to 66.4% on the postintervention test; a statistically significant improvement of 14.3 percentage points (P<.001; 95% CI 9.8-18.9) with intention-to-treat analysis. Analysis of participants who received the intervention as per protocol (500 patient cases in 8 days) showed an average increase of 16.7 percentage points (P<.001; 95% CI 11.3-22.0) from 53.9% to 70.5%. Their overall ability to correctly recognize malignant lesions in the LIIR patient cases improved over the intervention period by 6.6 percentage points from 67.1% (95% CI 65.2-69.3) to 73.7% (95% CI 72.5-75.0) and their ability to set the correct diagnosis improved by 10.5 percentage points from 42.5% (95% CI 40.2%-44.8%) to 53.0% (95% CI 51.3-54.9). The diagnostic confidence of participants in the intervention group increased on a scale from 1 to 4 by 32.9% from 1.6 to 2.1 (P<.001). Participants in the control group did not increase their postintervention score or their diagnostic confidence during the same period.

CONCLUSIONS

Self-paced pattern recognition training in skin cancer diagnostics through the use of a digital LIIR with patient cases delivered by a quiz-based mobile app improves the diagnostic accuracy of PCPs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05661370; https://classic.clinicaltrials.gov/ct2/show/NCT05661370.

Electrical impedance spectroscopy significantly enhances correct biopsy choice for pigmented skin lesions beyond clinical evaluation and dermoscopy

The purpose of this study was to investigate whether EIS technology can further improve correct biopsy choices beyond clinical and dermoscopic evaluation for melanoma (MM), severe dysplastic nevi (SDN) and benign PSLs. Images of 49 MMs, SDNs and benign PSLs were randomly selected from a prior study and were provided in a reader-type survey study to dermatologists to evaluate for biopsy. A total of 33,957 biopsy decisions were analyzed. Respondents significantly improved on the correct biopsy choice with the addition of dermoscopy versus clinical image alone for melanoma and severely dysplastic nevi. Respondents also showed a statistically significant improvement in correct biopsy choice beyond their dermoscopic evaluation when integrating the EIS score versus dermoscopy with clinical images for MM, SDN and benign lesions. Respondents also made fewer incorrect biopsy choices with the addition of the EIS score versus dermoscopy and clinical image for MM and benign lesions. Sub-analyses of biopsy choices were also conducted based on experience and practice type. The findings from this study demonstrate that the integration of EIS technology into PSL biopsy decisions has the potential to significantly improve the accuracy of lesion selection for biopsy beyond clinical and dermoscopic evaluation alone.

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.

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.

Profile of the use of dermoscopy among dermatologists in Brazil (2018)

BACKGROUND

Dermoscopy increases the diagnostic accuracy in dermatology. The aspects related to training, usage profile, or perceptions of usefulness of dermoscopy among dermatologists in Brazil have not been described.

OBJECTIVES

To evaluate the profile of the use of dermoscopy and the perception of the impact of the technique on clinical practice.

METHODS

The Brazilian Society of Dermatology invited all members to complete an online form with 20 items regarding demographic data, dermatological assistance, use of dermoscopy, and perceptions of the impact of the technique on clinical practice. The proportions between the categories were compared by analysis of residuals in contingency tables, and p-values < 0.01 were considered significant.

RESULTS

The answers from 815 associates (9.1% of those invited to participate) were assessed, 84% of whom were female, and 71% of whom were younger than 50 years of age. The use of dermoscopy was reported in the daily practice of 98% of dermatologists: 88% reported using it more than once a day. Polarized light dermoscopy was the most used method (83%) and pattern analysis was the most used algorithm (63%). The diagnosis and follow-up of melanocytic lesions was identified as the main use of the technique, while the benefit for the diagnosis of inflammatory lesions was acknowledged by less than half of the sample (42%).

STUDY LIMITATIONS

This was a non-randomized study.

CONCLUSION

Dermoscopy is incorporated into the clinical practice of almost all Brazilian dermatologists, and it is recognized for increasing diagnostic certainty in different contexts, especially for pigmented lesions.

Meta-analysis of number needed to treat for diagnosis of melanoma by clinical setting

OBJECTIVE

To provide a formal statistical comparison of the efficacy of melanoma detection among different clinical settings.

METHODS

A systematic review and meta-analysis of all relevant observational studies on number needed to treat (NNT) in relation to melanoma was performed in MEDLINE. We performed a random-effects model meta-analysis and reported NNTs with 95% confidence intervals (CIs). The subgroup analysis was related to clinical setting.

RESULTS

In all, 29 articles including a total of 398,549 biopsies/excisions were analyzed. The overall NNT was 9.71 (95% CI, 7.72-12.29): 22.62 (95% CI, 12.95-40.10) for primary care, 9.60 (95% CI, 6.97-13.41) for dermatology, and 5.85 (95% CI, 4.24-8.27) for pigmented lesion specialists.

LIMITATIONS

There is heterogeneity in data reporting and the possibility of missing studies. In addition, the incidence of melanoma varies among clinical settings, which could affect NNT calculations.

CONCLUSION

Pigmented lesion specialists have the lowest NNT, followed by dermatologists, suggesting that involving specialists in the diagnosis and treatment of pigmented skin lesions can likely improve patient outcomes.

Evaluation of the Number-Needed-to-Biopsy Metric for the Diagnosis of Cutaneous Melanoma: A Systematic Review and Meta-analysis

Importance

To date, no concerted effort has been made to date to evaluate the literature on number-needed-to-biopsy (NNB) metrics, particularly to account for the differences in clinician type and melanoma prevalence in certain geographic locations.

Objective

To review and synthesize worldwide data for NNB for the diagnosis of cutaneous melanoma.

Data Source

MEDLINE, Embase, and PubMed databases were searched for English-language articles published worldwide from January 1, 2000, to November 28, 2018.

Study Selection

A total of 46 studies were included that addressed NNB for at least 3681 clinicians worldwide and included 455 496 biopsied tumors and 29 257 melanomas; primary care practitioner (PCP) data were only available from Australia.

Data Extraction and Synthesis

Articles were screened for eligibility, and possible overlapping data sets were resolved. Data extracted included clinician specialization, use of dermoscopy, geographic region and location-specific health care system, study design, number of benign tumors, number of melanomas, and NNB. The review followed the PRISMA guidelines.

Main Outcome and Measures

The NNB for the diagnosis of cutaneous melanoma.

Results

A total of 46 studies were included that addressed NNB for at least 3681 clinicians worldwide and included 455 496 biopsied tumors and 29 257 melanomas; primary care practitioner (PCP) data were only available from Australia. The reported NNB ranged from 2.2 to 287, and the weighted mean NNB for all included publications was 15.6. The exclusion of publications structured as all biopsied tumors, owing to variable data characterization, resulted in reported NNB ranging from 2.2 to 30.5, with a global weighted mean NNB of 14.8 for all clinicians, 7.5 for all dermatologists, 14.6 for Australian PCPs, and 13.2 for all US-based dermatological practitioners, including dermatologists and advanced practice professionals. The summary effect size (ES) demonstrates that a mean 4% of biopsies demonstrated melanoma for study stratum A (all biopsied skin tumors, ES, 0.04; 95% CI, 0.03-0.05), and a mean 12% of biopsies demonstrated melanoma for study strata B (melanocytic tumors on pathology review, ES, 0.12; 95% CI, 0.10-0.14) and C (clinical concern for melanoma, ES; 0.12; 95% CI, 0.09-0.14).

Conclusions and Relevance

The existing NNB for cutaneous melanoma appeared to vary widely worldwide, lacking standardization in the metric and its reporting, and according to clinician characteristics as well; the NNB of US-based clinicians may warrant further exploration.

Can Dermoscopy Serve as a Diagnostic Tool in Dermatophytosis? A Pilot Study

Background

Dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders.

Aim

The purpose of the study was to describe the dermoscopic findings in various dermatophytosis.

Materials and Methods

This cross-sectional study included 100 clinically diagnosed tinea infections of skin, hair, and nails, which were evaluated using a dermoscope (Dermlite 3 gen DL3N, California USA, 10x).

Results

Among 100 patients of dermatophytosis, 69 were males and 31 females. The maximum number of patients had tinea corporis, followed by tinea cruris and tinea capitis. Dermoscopic findings noted in cases of tinea corporis included diffuse erythema, follicular micropustules, and brown spots surrounded by a white-yellowish halo, broken hair, wavy hair, and rare, morse code hair. Dermoscopy of tinea capitis depicted comma hairs, corkscrew hairs, zigzag hairs, and morse code hairs. Proximal jagged edge, spikes, and longitudinal striations were present in the cases of onychomycosis. Dermoscopy of tinea incognito yielded morse code hairs, follicular micropustules, and easily deformable hairs that look weakened and transparent and show unusual bends.

Limitations

Dermoscopic findings were not correlated to fungal culture.

Conclusion

Dermoscopy can be used as a fast, inexpensive, and noninvasive diagnostic tool to enhance diagnosis of cutaneous fungal infections.

Visual inspection for diagnosing cutaneous melanoma in adults

BACKGROUND

Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. History-taking and visual inspection of a suspicious lesion by a clinician is usually the first in a series of 'tests' to diagnose skin cancer. Establishing the accuracy of visual inspection alone is critical to understating the potential contribution of additional tests to assist in the diagnosis of melanoma.

OBJECTIVES

To determine the diagnostic accuracy of visual inspection for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with limited prior testing and in those referred for further evaluation of a suspicious lesion. Studies were separated according to whether the diagnosis was recorded face-to-face (in-person) or based on remote (image-based) assessment.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Test accuracy studies of any design that evaluated visual inspection in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. We excluded studies reporting data for 'clinical diagnosis' where dermoscopy may or may not have been used.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities per algorithm and threshold using the bivariate hierarchical model. We investigated the impact of: in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; and observer expertise.

MAIN RESULTS

We included 49 publications reporting on a total of 51 study cohorts with 34,351 lesions (including 2499 cases), providing 134 datasets for visual inspection. Across almost all study quality domains, the majority of study reports provided insufficient information to allow us to judge the risk of bias, while in three of four domains that we assessed we scored concerns regarding applicability of study findings as 'high'. Selective participant recruitment, lack of detail regarding the threshold for deciding on a positive test result, and lack of detail on observer expertise were particularly problematic.Attempts to analyse studies by degree of prior testing were hampered by a lack of relevant information and by the restricted inclusion of lesions selected for biopsy or excision. Accuracy was generally much higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio of 8.54, 95% CI 2.89 to 25.3, P < 0.001). Meta-analysis of in-person evaluations that could be clearly placed on the clinical pathway showed a general trade-off between sensitivity and specificity, with the highest sensitivity (92.4%, 95% CI 26.2% to 99.8%) and lowest specificity (79.7%, 95% CI 73.7% to 84.7%) observed in participants with limited prior testing (n = 3 datasets). Summary sensitivities were lower for those referred for specialist assessment but with much higher specificities (e.g. sensitivity 76.7%, 95% CI 61.7% to 87.1%) and specificity 95.7%, 95% CI 89.7% to 98.3%) for lesions selected for excision, n = 8 datasets). These differences may be related to differences in the spectrum of included lesions, differences in the definition of a positive test result, or to variations in observer expertise. We did not find clear evidence that accuracy is improved by the use of any algorithm to assist diagnosis in all settings. Attempts to examine the effect of observer expertise in melanoma diagnosis were hindered due to poor reporting.

AUTHORS' CONCLUSIONS

Visual inspection is a fundamental component of the assessment of a suspicious skin lesion; however, the evidence suggests that melanomas will be missed if visual inspection is used on its own. The evidence to support its accuracy in the range of settings in which it is used is flawed and very poorly reported. Although published algorithms do not appear to improve accuracy, there is insufficient evidence to suggest that the 'no algorithm' approach should be preferred in all settings. Despite the volume of research evaluating visual inspection, further prospective evaluation of the potential added value of using established algorithms according to the prior testing or diagnostic difficulty of lesions may be warranted.

Visual inspection and dermoscopy, alone or in combination, for diagnosing keratinocyte skin cancers in adults

BACKGROUND

Early accurate detection of all skin cancer types is important to guide appropriate management, to reduce morbidity and to improve survival. Basal cell carcinoma (BCC) is almost always a localised skin cancer with potential to infiltrate and damage surrounding tissue, whereas a minority of cutaneous squamous cell carcinomas (cSCCs) and invasive melanomas are higher-risk skin cancers with the potential to metastasise and cause death. Dermoscopy has become an important tool to assist specialist clinicians in the diagnosis of melanoma, and is increasingly used in primary-care settings. Dermoscopy is a precision-built handheld illuminated magnifier that allows more detailed examination of the skin down to the level of the superficial dermis. Establishing the value of dermoscopy over and above visual inspection for the diagnosis of BCC or cSCC in primary- and secondary-care settings is critical to understanding its potential contribution to appropriate skin cancer triage, including referral of higher-risk cancers to secondary care, the identification of low-risk skin cancers that might be treated in primary care and to provide reassurance to those with benign skin lesions who can be safely discharged.

OBJECTIVES

To determine the diagnostic accuracy of visual inspection and dermoscopy, alone or in combination, for the detection of (a) BCC and (b) cSCC, in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in person) or based on remote (image-based) assessment.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies of any design that evaluated visual inspection or dermoscopy or both in adults with lesions suspicious for skin cancer, compared with a reference standard of either histological confirmation or clinical follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic thresholds were missing. We estimated accuracy using hierarchical summary ROC methods. We undertook analysis of studies allowing direct comparison between tests. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely-developed algorithm to assist diagnosis; and observer expertise.

MAIN RESULTS

We included 24 publications reporting on 24 study cohorts, providing 27 visual inspection datasets (8805 lesions; 2579 malignancies) and 33 dermoscopy datasets (6855 lesions; 1444 malignancies). The risk of bias was mainly low for the index test (for dermoscopy evaluations) and reference standard domains, particularly for in-person evaluations, and high or unclear for participant selection, application of the index test for visual inspection and for participant flow and timing. We scored concerns about the applicability of study findings as of 'high' or 'unclear' concern for almost all studies across all domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The detection of BCC was reported in 28 datasets; 15 on an in-person basis and 13 image-based. Analysis of studies by prior testing of participants and according to observer expertise was not possible due to lack of data. Studies were primarily conducted in participants referred for specialist assessment of lesions with available histological classification. We found no clear differences in accuracy between dermoscopy studies undertaken in person and those which evaluated images. The lack of effect observed may be due to other sources of heterogeneity, including variations in the types of skin lesion studied, in dermatoscopes used, or in the use of algorithms and varying thresholds for deciding on a positive test result.Meta-analysis found in-person evaluations of dermoscopy (7 evaluations; 4683 lesions and 363 BCCs) to be more accurate than visual inspection alone for the detection of BCC (8 evaluations; 7017 lesions and 1586 BCCs), with a relative diagnostic odds ratio (RDOR) of 8.2 (95% confidence interval (CI) 3.5 to 19.3; P < 0.001). This corresponds to predicted differences in sensitivity of 14% (93% versus 79%) at a fixed specificity of 80% and predicted differences in specificity of 22% (99% versus 77%) at a fixed sensitivity of 80%. We observed very similar results for the image-based evaluations.When applied to a hypothetical population of 1000 lesions, of which 170 are BCC (based on median BCC prevalence across studies), an increased sensitivity of 14% from dermoscopy would lead to 24 fewer BCCs missed, assuming 166 false positive results from both tests. A 22% increase in specificity from dermoscopy with sensitivity fixed at 80% would result in 183 fewer unnecessary excisions, assuming 34 BCCs missed for both tests. There was not enough evidence to assess the use of algorithms or structured checklists for either visual inspection or dermoscopy.Insufficient data were available to draw conclusions on the accuracy of either test for the detection of cSCCs.

AUTHORS' CONCLUSIONS

Dermoscopy may be a valuable tool for the diagnosis of BCC as an adjunct to visual inspection of a suspicious skin lesion following a thorough history-taking including assessment of risk factors for keratinocyte cancer. The evidence primarily comes from secondary-care (referred) populations and populations with pigmented lesions or mixed lesion types. There is no clear evidence supporting the use of currently-available formal algorithms to assist dermoscopy diagnosis.

Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults

BACKGROUND

Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Although history-taking and visual inspection of a suspicious lesion by a clinician are usually the first in a series of 'tests' to diagnose skin cancer, dermoscopy has become an important tool to assist diagnosis by specialist clinicians and is increasingly used in primary care settings. Dermoscopy is a magnification technique using visible light that allows more detailed examination of the skin compared to examination by the naked eye alone. Establishing the additive value of dermoscopy over and above visual inspection alone across a range of observers and settings is critical to understanding its contribution for the diagnosis of melanoma and to future understanding of the potential role of the growing number of other high-resolution image analysis techniques.

OBJECTIVES

To determine the diagnostic accuracy of dermoscopy alone, or when added to visual inspection of a skin lesion, for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in-person), or based on remote (image-based), assessment.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies of any design that evaluated dermoscopy in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. Data on the accuracy of visual inspection, to allow comparisons of tests, was included only if reported in the included studies of dermoscopy.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated accuracy using hierarchical summary receiver operating characteristic (SROC),methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; observer expertise; and dermoscopy training.

MAIN RESULTS

We included a total of 104 study publications reporting on 103 study cohorts with 42,788 lesions (including 5700 cases), providing 354 datasets for dermoscopy. The risk of bias was mainly low for the index test and reference standard domains and mainly high or unclear for participant selection and participant flow. Concerns regarding the applicability of study findings were largely scored as 'high' concern in three of four domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The accuracy of dermoscopy for the detection of invasive melanoma or atypical intraepidermal melanocytic variants was reported in 86 datasets; 26 for evaluations conducted in person (dermoscopy added to visual inspection), and 60 for image-based evaluations (diagnosis based on interpretation of dermoscopic images). Analyses of studies by prior testing revealed no obvious effect on accuracy; analyses were hampered by the lack of studies in primary care, lack of relevant information and the restricted inclusion of lesions selected for biopsy or excision. Accuracy was higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio (RDOR) 4.6, 95% confidence interval (CI) 2.4 to 9.0; P < 0.001).We compared accuracy for (a), in-person evaluations of dermoscopy (26 evaluations; 23,169 lesions and 1664 melanomas),versus visual inspection alone (13 evaluations; 6740 lesions and 459 melanomas), and for (b), image-based evaluations of dermoscopy (60 evaluations; 13,475 lesions and 2851 melanomas),versus image-based visual inspection (11 evaluations; 1740 lesions and 305 melanomas). For both comparisons, meta-analysis found dermoscopy to be more accurate than visual inspection alone, with RDORs of (a), 4.7 (95% CI 3.0 to 7.5; P < 0.001), and (b), 5.6 (95% CI 3.7 to 8.5; P < 0.001). For a), the predicted difference in sensitivity at a fixed specificity of 80% was 16% (95% CI 8% to 23%; 92% for dermoscopy + visual inspection versus 76% for visual inspection), and predicted difference in specificity at a fixed sensitivity of 80% was 20% (95% CI 7% to 33%; 95% for dermoscopy + visual inspection versus 75% for visual inspection). For b) the predicted differences in sensitivity was 34% (95% CI 24% to 46%; 81% for dermoscopy versus 47% for visual inspection), at a fixed specificity of 80%, and predicted difference in specificity was 40% (95% CI 27% to 57%; 82% for dermoscopy versus 42% for visual inspection), at a fixed sensitivity of 80%.Using the median prevalence of disease in each set of studies ((a), 12% for in-person and (b), 24% for image-based), for a hypothetical population of 1000 lesions, an increase in sensitivity of (a), 16% (in-person), and (b), 34% (image-based), from using dermoscopy at a fixed specificity of 80% equates to a reduction in the number of melanomas missed of (a), 19 and (b), 81 with (a), 176 and (b), 152 false positive results. An increase in specificity of (a), 20% (in-person), and (b), 40% (image-based), at a fixed sensitivity of 80% equates to a reduction in the number of unnecessary excisions from using dermoscopy of (a), 176 and (b), 304 with (a), 24 and (b), 48 melanomas missed.The use of a named or published algorithm to assist dermoscopy interpretation (as opposed to no reported algorithm or reported use of pattern analysis), had no significant impact on accuracy either for in-person (RDOR 1.4, 95% CI 0.34 to 5.6; P = 0.17), or image-based (RDOR 1.4, 95% CI 0.60 to 3.3; P = 0.22), evaluations. This result was supported by subgroup analysis according to algorithm used. We observed higher accuracy for observers reported as having high experience and for those classed as 'expert consultants' in comparison to those considered to have less experience in dermoscopy, particularly for image-based evaluations. Evidence for the effect of dermoscopy training on test accuracy was very limited but suggested associated improvements in sensitivity.

AUTHORS' CONCLUSIONS

Despite the observed limitations in the evidence base, dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants, particularly in referred populations and in the hands of experienced users. Data to support its use in primary care are limited, however, it may assist in triaging suspicious lesions for urgent referral when employed by suitably trained clinicians. Formal algorithms may be of most use for dermoscopy training purposes and for less expert observers, however reliable data comparing approaches using dermoscopy in person are lacking.

Utility of a Noninvasive 2-Gene Molecular Assay for Cutaneous Melanoma and Effect on the Decision to Biopsy

Importance

Expression of long intergenic non-protein coding RNA 518 (LINC00518) and preferentially expressed antigen in melanoma (PRAME) genes, obtained via noninvasive adhesive patch biopsy, is a sensitive and specific method for detection of cutaneous melanoma. However, the utility of this test in biopsy decisions made by dermatologists has not been evaluated.

Objective

To determine the utility of the pigmented lesion assay (PLA) for LINC00518/PRAME expression in decisions to biopsy a series of pigmented skin lesions.

Design, Setting, and Participants

In this secure web-based, multiple-reader-multiple-case study, 45 board-certified dermatologists each evaluated 60 clinical and dermoscopic images of clinically atypical pigmented lesions, first without and then with PLA gene expression information and were asked whether the lesions should be biopsied. Data were collected from March 24, 2014, through November 13, 2015.

Interventions

Participants were given a report for each lesion, which included the results of an assay for expression of LINC00518/PRAME and a PLA score with data on the predictive values of the information provided.

Main Outcomes and Measures

Biopsy sensitivity and specificity with vs without PLA data.

Results

Forty-five dermatologists (29 male and 16 female) performed the evaluation. After incorporating the PLA into their decision as to whether to biopsy a pigmented lesion suggestive of melanoma, dermatologists improved their mean biopsy sensitivity from 95.0% to 98.6% (P = .01); specificity increased from 32.1% to 56.9% (P < .001) with PLA data.

Conclusions and Relevance

The noninvasive PLA enables dermatologists to significantly improve biopsy specificity while maintaining or improving sensitivity. This result may increase the number of early melanomas biopsied and reduce the number of benign lesions biopsied, thereby improving patient outcomes and reducing health care costs.

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.

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.

Development and validation of a noninvasive 2-gene molecular assay for cutaneous melanoma

Background

Clinical and histopathologic assessment of pigmented skin lesions remains challenging even for experts. Differentiated and accurate noninvasive diagnostic modalities are highly desirable.

Objective

We sought to provide clinicians with such a tool.

Methods

A 2-gene classification method based on LINC00518 and preferentially expressed antigen in melanoma (PRAME) gene expression was evaluated and validated in 555 pigmented lesions (157 training and 398 validation samples) obtained noninvasively via adhesive patch biopsy. Results were compared with standard histopathologic assessment in lesions with a consensus diagnosis among 3 experienced dermatopathologists.

Results

In 398 validation samples (87 melanomas and 311 nonmelanomas), LINC00518 and/or PRAME detection appropriately differentiated melanoma from nonmelanoma samples with a sensitivity of 91% and a specificity of 69%. We established LINC00518 and PRAME in both adhesive patch melanoma samples and underlying formalin fixed paraffin embedded (FFPE) samples of surgically excised primary melanomas and in melanoma lymph node metastases.

Limitations

This technology cannot be used on mucous membranes, palms of hands, and soles of feet.

Conclusions

This noninvasive 2-gene pigmented lesion assay classifies pigmented lesions into melanoma and nonmelanoma groups and may serve as a tool to help with diagnostic challenges that may be inherently linked to the visual image and pattern recognition approach.

Raman Spectroscopic Characterization of Melanoma and Benign Melanocytic Lesions Suspected of Melanoma Using High-Wavenumber Raman Spectroscopy

Melanoma is a pigmented type of skin cancer, which has the highest mortality of all skin cancers. Because of the low clinical diagnostic accuracy for melanoma, an objective tool is needed to assist clinical assessment of skin lesions that are suspected of (early) melanoma. The aim of this study was to identify spectral differences in the CH region of HWVN (high-wavenumber) Raman spectra between melanoma and benign melanocytic lesions clinically suspected of melanoma. We used these spectral differences to explore preliminary classification models to distinguish melanoma from benign melanocytic lesions. Data from 82 freshly excised melanocytic lesions clinically suspected of melanoma were measured using an in-house built Raman spectrometer, which has been optimized for measurements on pigmented skin lesions (excitation wavelength 976 nm and a wavelength range of the Raman signal 1340-1540 nm). Clear spectral differences were observed between melanoma and benign melanocytic lesions. These differences can be assigned mainly to the symmetric CH2 stretching vibrations of lipids. Our results show that the Raman bands between 2840 and 2930 cm(-1) have increased intensity for melanoma when compared to benign melanocytic lesions, suggesting an increase in lipid content in melanoma. These results demonstrate that spectroscopic information in the CH-stretching region of HWVN Raman spectra can discriminate melanoma from benign melanocytic lesions that are often clinically misdiagnosed as melanoma and that Raman spectroscopy has the potential to provide an objective clinical tool to improve the clinical diagnostic accuracy of skin lesions suspected of melanoma.

Guidelines of the Brazilian Dermatology Society for diagnosis, treatment and follow up of primary cutaneous melanoma--Part I

The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In the first part, the following clinical questions were answered: 1) The use of dermoscopy for diagnosis of primary cutaneous melanoma brings benefits for patients when compared with clinical examination? 2) Does dermoscopy favor diagnosis of nail apparatus melanoma? 3) Is there a prognostic difference when incisional or excisional biopsies are used? 4) Does revision by a pathologist trained in melanoma contribute to diagnosis and treatment of primary cutaneous melanoma? What margins should be used to treat lentigo maligna melanoma and melanoma in situ?

Impact of in vivo reflectance confocal microscopy on the number needed to treat melanoma in doubtful lesions

BACKGROUND

The number needed to treat (NNT) ratio is an effective method for measuring accuracy in melanoma detection. Dermoscopy reduces the number of false positives and subsequently unnecessary excisions. In vivo reflectance confocal microscopy (RCM) is a noninvasive technique that allows examination of the skin with cellular resolution.

OBJECTIVES

To assess the impact of RCM analysis on the number of equivocal lesions, assumed to be melanocytic, excised for every melanoma.

METHODS

Consecutive patients (n = 343) presenting with doubtful lesions were considered for enrolment. The lesions were analysed by dermoscopy and RCM, with histopathological assessment considered the reference standard. The main outcome was the NNT, calculated as the proportion of equivocal lesions excised for every melanoma.

RESULTS

Dermoscopy alone obtained a hypothetical NNT of 3·73; the combination of dermoscopy and RCM identified 264 equivocal lesions that qualified for excision, 92 of which were confirmed to be a melanoma, resulting in an NNT of 2·87, whereas the analysis of RCM images classified 103 lesions as melanoma, with a consequent NNT of 1·12. The difference in the reduction of this ratio was statistically significant between the three groups (P < 0·0001). There was no significant improvement in sensitivity when comparing the combination of dermoscopy and RCM with RCM alone (94·6% vs. 97·8%; P = 0·043). However, the differences between specificities were statistically significant (P < 1 × 10(-6) ), favouring RCM alone.

CONCLUSION

The addition of RCM analysis to dermoscopy reduces unnecessary excisions with a high diagnostic accuracy and could be a means for reducing the economic impact associated with the management of skin cancer.

Integration of reflectance confocal microscopy in sequential dermoscopy follow-up improves melanoma detection accuracy

BACKGROUND

Successful treatment of melanoma depends on early diagnosis, but its varied clinical presentation means that no single noninvasive method or criterion can provide reliable detection in all cases.

OBJECTIVES

To determine whether combining sequential dermoscopy imaging with reflectance confocal microscopy (RCM) can improve melanoma detection and reduce the burden of unnecessary excisions.

METHODS

We conducted a retrospective study with median follow-up of 25 months. We included equivocal pigmented lesions that lacked clear dermoscopy criteria for melanoma at baseline but were excised subsequently because of changes during digital monitoring. RCM imaging was performed before excision. Main melanoma dermoscopy features, seven-point checklist score at baseline, and changes in structure and/or colour, and development of new melanoma-specific criteria at follow-up (scored as major, moderate or minor) were considered. Main melanoma RCM criteria were evaluated and diagnosis was made. Histopathological diagnosis was the reference standard for defining parameter frequency and diagnostic accuracy.

RESULTS

Seventy lesions were included. Major changes were more frequently correlated with melanoma diagnosis, although one-third (four of 12) of melanomas showed moderate or minor changes. Cytological atypia and architectural disarrangement on RCM were correlated with melanoma diagnosis. A correct melanoma diagnosis was achieved with RCM in almost all cases (11 of 12, 92%). Referring for excision only those lesions with RCM-positive features and/or presenting major changes at digital dermoscopy follow-up, theoretically 27 of 58 naevi could be saved from surgery.

CONCLUSIONS

Integration of RCM in the clinical and instrumental strategy for managing difficult pigmented lesions provided additional diagnostic information useful in the decision-making process.

Skin cancer screening and primary prevention: facts and controversies

Skin cancer is both common and responsible for significant morbidity and mortality. Opportunities for both primary and secondary prevention are available to both dermatologists and non-dermatologists. Counseling selected patients about ultraviolet avoidance and proper use of sunscreens is recommended. Due to technical and financial barriers, no study has conclusively confirmed the benefits of skin cancer screening. Both dermatologists and non-dermatologists often do not perform total body skin examinations during clinical encounters, despite high acceptance rates by patients. Many non-dermatologists would benefit from additional education pertaining to the diagnosis of cutaneous malignancy. Teledermatology may have a role in areas with poor access to dermatologists. There are ample opportunities for more to be learned in the future.

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.

Advances in dermoscopy for detecting melanocytic lesions

Over the last 30 years dermatological approaches to diagnosis and management of melanocytic lesions have been revolutionized by the introduction of dermoscopy. Continuous improvements are being made in applying the technique, mostly in melanoma diagnosis, follow-up of melanocytic lesions and nevogenesis. Identification of new dermoscopic criteria, such as the dermoscopic island and the blue-black color for thin and nodular melanoma, respectively, further add two new weapons in the dermoscopical armamentarium for diagnosis of otherwise featureless melanoma. Recent advances show that short-term, 3-month, follow-up is the optimum time interval to identify minimal changes in initially featureless melanomas. Nevertheless, long-term follow-up is still useful for the recognition of changes in melanomas with a very low-rate of growth. Dermoscopy greatly improves diagnosis and early excision of melanomas and reduces the number of unnecessary excisions.

Up-to-date non-invasive visualization technologies in dermatology

The authors present a review of up-to-date non-invasive visualization methods used in diagnostics of diseases of skin and its appendages. They describe physical principles forming the basis for non-invasive visualization methods such as dermatoscopy, confocal laser scanning microscopy, optical video monitoring, optical topometry, optical coherent tomography, ultrasound scanning, 3D-modeling. They also describe the potential of practical application of these diagnostics methods at the current stage of their development. The authors have demonstrated that it is possible to reduce the clinicians need in biopsy diagnostics due to the high information value of non-invasive visual diagnostics methods.