Dermoscopy Training Effect on Diagnostic Accuracy of Skin Lesions in Canadian Family Medicine Physicians Using the Triage Amalgamated Dermoscopic Algorithm

Background

Accurate identification of cutaneous lesions is an essential skill for family medicine physicians (FMPs). Studies show significant improvement in skin cancer detection with dermoscopy use. Frontline FMPs are an ideal target group for dermoscopy training. The 3-step Triage Amalgamated Dermoscopic Algorithm (TADA) facilitates high sensitivity and specificity for pigmented and nonpigmented skin lesions. Step I requires unequivocal identification of dermoscopic features for 1 of 3 benign skin lesions: angioma, dermatofibroma, or seborrheic keratosis. If absent, steps II and III are applied assessing for features of architectural disorder and malignancies with organized, symmetric patterns, respectively.

Objective

To assess FMPs' diagnostic accuracy of benign and malignant skin lesions before and after training in TADA step I.

Methods

In this repeated-measures observational study, 33 dermoscopy-naive FMPs attending an introductory dermoscopy workshop each assessed gross and corresponding dermoscopic photographic images of 50 pigmented and nonpigmented skin lesions (23 benign, 27 malignant) for features of TADA step I lesions before and after training. Analyses compared diagnostic accuracy in relation to training and baseline physician characteristics.

Results

Diagnostic accuracy improved from 76.4% to 90.8% (P < 0.001) and from 85.0% to 90.0% (P = 0.01), respectively, for all lesions and for all TADA I lesions. Female sex was significant as a predictor of individual posttraining performance (all lesions combined, P = 0.02).

Conclusions

Results show significant improvement in diagnostic accuracies for benign and malignant skin lesions with introductory dermoscopy training using TADA step I. This will reduce unnecessary benign lesion excision and enhance referral sensitivity, conserving specialist resources.

Dermoscopy of Small Diameter Melanomas with the Diagnostic Feasibility of Selected Algorithms-A Clinical Retrospective Multicenter Study

Simple Summary

The early detection of melanoma determines the recovery of the patient. Dermoscopy, which is one of the diagnostic tools for pigmented lesions, is characterized by high sensitivity and specificity, giving the clinician the possibility to detect the presence of abnormal structures before their clinical presentation. There are a small number of dermoscopic analyses of pigmented lesions of less than 6 mm in diameter in the published literature. The authors attempted to identify characteristic dermoscopic structures typical for melanomas of less than 5 mm in diameter in comparison with a group of melanomas exceeding this dimension at an identical clinical stage. It was found that dermoscopy in the secondary prevention of micromelanomas (appearing mainly as brown lesions) revealed the presence of dotted or polymorphous vessels, with architectural disorder in half of cases. Moreover, spitzoid, multicomponent asymmetric or nonmelanoma-specific patterns prevailed. Knowledge of these dermoscopic features brings the clinician closer to an early diagnosis of melanoma with a diameter of 5 mm or less.

Abstract

Objective: The aim of the study was to verify two hypotheses. The first concerned the possibility of diagnostic dermoscopic differentiation between cutaneous melanomas of the histopathological category in situ (pTis) and thin melanomas (pT1a) in terms of their diameter. The second assessed the diagnostic feasibility of two dermoscopic algorithms aiming to detect ≤ 5.0 mm-sized melanomas histopathologically confirmed as pTis and pT1a. Methods: Dermoscopic images of consecutive cases of histopathologically confirmed melanomas were evaluated by three independent investigators for the presence of the predefined criteria. The melanomas were subdivided according to their diameter into small melanomas, so-called micromelanomas (microM)—sized ≤ 5.0 mm and >5.0 mm, according to published definitions of small melanocytic lesions. The Triage Amalgamated Dermoscopic Algorithm (TADA) and the revisited 7-point checklist of dermoscopy (7-point) algorithm were chosen for the diagnostic feasibility. Odds ratios and corresponding 95% confidence limits (CL) were calculated using the logistic regression adjusted for age for the melanoma-specific dermoscopic structures, the dermoscopic patterns and the diagnostic feasibility of the 7-point checklist and TADA algorithms. The p-values of the results were corrected using the Bonferroni method. Results: In total, 106 patients with 109 melanomas, 50 sized ≤ 5.0 mm and 59 exceeding the diameter of 5.0 mm, were retrospectively analyzed. The prevalent general pattern of microM was the spitzoid one (48% vs. 11.86%, p = 0.0013). Furthermore, 40% of microM vs. 6.78% melanomas sized > 5.0 mm (p = 0.0023) did not present melanoma-specific patterns. The asymmetric multicomponent pattern was present in 64.41% melanomas sized > 5.0 mm and in 26.00% microM (p = 0.0034). The asymmetry of structures or colors was detected in 56% microM vs. 89.83% (p = 0.0020) and 56% microM and 94.92% (p = 0.000034) melanoma sized > 5.0 mm, respectively. The differences in frequency of the detected dermoscopic structures specific to melanomas revealed that microM are almost deprived of negative networks (p = 0.04), shiny white structures (p = 0.0027) and regression features (p = 0.00003). Neither prominent skin markings nor angulated lines were found in the entire study group. Out of the vascular structures, microM presented only dotted (32%) or polymorphous (28%) vessels, although more rarely than melanomas sized > 5.0 mm (66.1% p = 0.017 and 49% p > 0.05, respectively). The diagnostic feasibility revealed a score ≥ 3 of the 7-point algorithm (indicative for malignancy) in 60% microM and 98.31% melanomas sized > 5.0 mm (p = 0.000006). The TADA algorithm revealed melanoma-specific patterns in 64% microM and 96.61% > 5.0 mm-sized melanomas (p = 0.00006) and melanoma-specific structures in 72% and 91.53% (p > 0.05), respectively. Conclusion: In the dermoscopy, 40% of micromelanomas histopathologically staged as pTis and pT1a did not reveal melanoma-specific patterns. Among the general melanocytic patterns, the spitzoid one was the most frequently found in melanomas sized ≤ 5.0 mm. The 7-point checklist and TADA dermoscopic algorithms were helpful in the identification of the majority of melanomas sized ≤ 5.0 mm.

Impact of Dermoscopy Training on Diagnostic Accuracy, and Its Association With Biopsy and Referral Patterns Among Primary Care Providers: A Retrospective and Prospective Educational Intervention Study

BACKGROUND

Proper diagnosis in primary care is crucial due to the large number of skin cancer diagnoses each year and its associated growing economic burden. Understanding how primary care providers can be best trained in dermoscopy is instrumental in helping primary care providers differentiate benign and malignant cutaneous lesions so that appropriate action can be taken (eg, biopsy/referral to dermatology or reassurance).

OBJECTIVE

To assess the success of concise dermoscopy training among primary care providers.

DESIGN

A cohort study was conducted in primary care at Mayo Clinic, Rochester, including primary care physicians, nurse practitioners, and physician assistants in internal medicine and family medicine. Diagnostic accuracy was measured on standardized testing through image-based recognition and in clinical practice through observation of referral and biopsy patterns both before and after dermoscopy education, focused on the TADA plus method.

RESULTS

Forty-three primary care providers completed the image-based recognition tests, with significant improvement in mean score measured after dermoscopy training workshop (20%). Among the thirteen primary care providers who continued to use dermoscopy in clinical practice, a significant improvement (31%) in mean clinical diagnostic accuracy was observed comparing 1 year of practice data before versus after dermoscopy training.

CONCLUSION

Improvement in diagnostic accuracy with utilization of the TADA plus method translates into clinical practice. Therefore, training primary care providers in dermoscopy may improve the dermatologic care patients receive in primary care, especially in rural or medically underserved areas where access to dermatology is limited.