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

The Status of Dermoscopy in Chile: First National Study in Dermatologists

INTRODUCTION

Scientific evidence supports dermoscopy as an essential tool in dermatological diagnosis.

OBJECTIVES

The objective is to know the factors that influence its use in Chilean dermatologists.

METHODS

Analytical cross-sectional study. An adapted version of the survey was submitted from the pan-European study by Forsea et al to members of the Chilean Society of Dermatology, between September and December 2020. Analysis using descriptive statistics and multivariate analysis with ordinal logistic regression looking for factors associated with greater use of.

RESULTS

One hundred and ninety-eight responses, mean age 46.3 years and 14.6 years on average practicing as dermatologists. 61.6% trained in dermoscopy during their residency. 98% use a dermatoscope. More than 80% consider dermoscopy useful for the diagnosis of melanomas, follow-up of melanocytic lesions, and diagnosis of pigmented and non-pigmented tumors. Between 50% and 70% consider it useful for monitoring non-melanocytic lesions, nail and hair pathologies. Greater confidence when evaluating pigmented and non-pigmented tumors and capillary pathology. Adjusting for age, sex, confidence, and education, participation in teaching was associated with greater use of dermoscopy in non-pigmented and pigmented tumors, and capillary pathology.

CONCLUSIONS

Percentage of participation in the survey and training in dermoscopy higher than in the reference study, recognizing the usefulness of dermoscopy for the diagnosis and follow-up of tumor pathologies. Participating in teaching is a strong independent factor that is associated with a greater use of dermoscopy in Chile. Dermoscopy is positioned as a tool widely used by Chilean dermatologists in their daily practice.

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.

Handheld dermatoscope versus digital camera for hair counts in laser facial hair removal

The lack of uniform and objective techniques to evaluate treatment efficacy in photo-epilation studies leads to contradictory results. Thus, there is an urgent need to explore commonly accepted assessment tools. One of the most common methods uses hair counts via digital photography. However, macrophotography may not be able to depict the vellus-like hair induced by photo-epilation. On the other hand, handheld dermatoscopy is practical, affordable and offers high-quality magnification. Hair counts from a handheld dermatoscope and a digital camera were compared in 73 women who underwent 6 sessions with the Alexandrite 755 nm laser. Significantly more hairs were counted using the dermatoscope than using the digital camera (76.9 ± 41.3 vs. 58.6 ± 31.4, p < .005), independently of hair thickness and hair density. The difference in hair counts between the two instruments was inversely related to hair thickness and directly related to hair density. The handheld dermatoscope may be a more effective tool than the widely used digital camera in evaluating the response to laser hair removal treatment.

Which medical disciplines diagnose and treat melanoma in Europe in 2019? A survey of experts from melanoma centres in 27 European countries

BACKGROUND AND OBJECTIVES

The incidence of melanoma is increasing. This places significant burden on societies to provide efficient cancer care. The European Cancer Organisation recently published the essential requirements for quality melanoma care. The present study is aimed for the first time to roughly estimate the extent to which these requirements have been met in Europe.

MATERIALS AND METHODS

A web-based survey of experts from melanoma centres in 27 European countries was conducted from 1 February to 1 August 2019. Data on diagnostic techniques, surgical and medical treatment, organization of cancer care and education were collected and correlated with national health and economic indicators and mortality-to-incidence ratio (MIR) as a surrogate for survival. Univariate linear regression analysis was performed to evaluate the correlations. SPSS software was used. Statistical significance was set at P < 0.05.

RESULTS

The MIR was lower in countries with a high health expenditure per capita and with a higher numbers of general practitioners (GPs) and surgeons (SURG) per million inhabitants. In these countries, GPs and dermatologists (DER) were involved in melanoma detection; high percentage of DER used dermatoscopy and were involved in the follow-up of all melanoma stages; both medical oncologists (ONC) and dermato-oncologists administered systemic treatments; and patients had better access to sentinel lymph node biopsy and were treated within multidisciplinary tumour boards.

CONCLUSION

Based on these first estimates, the greater involvement of GPs in melanoma detection; the greater involvement of highly trained DER in dermatoscopy, dermatosurgery, follow-up and the systemic treatment of melanoma; and the provision of ongoing dermato-oncology training for pathologists, SURG, DER and ONC are necessary to provide an optimal melanoma care pathway. A comprehensive analysis of the melanoma care pathway based on clinical melanoma registries will be needed to more accurately evaluate these first insights.

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.

Melanoma Epidemiology and Early Detection in Europe: Diversity and Disparities

Melanoma claims annually more than 20,000 lives in Europe and is an important public health burden through its continuously increasing incidence and with its high mortality, costs, and complexity of care in advanced stages. Epidemiological surveillance is indispensable for the research into its causes, new prognostic markers, and innovative therapies, as well as for the building of efficient cancer control plans. However, important differences in the sources and availability of accurate epidemiological data exist among European countries and regions, contributing to a heterogeneous picture with 20-fold differences in the reported national melanoma incidence rates, divergent mortality trends, and solid disparities in survival across the Continent. Countries in the eastern half of Europe report the lowest incidence rates, but high case fatality, persisting and increasing mortality, a higher proportion of thicker tumors and late diagnosis, and lower survival rates. They are the least well equipped with quality cancer registration and reporting, and they lag behind in efficient cancer control plans implementation. This review highlights the main differences in melanoma epidemiology across Europe, together with an insight into their underlying causes in the areas of melanoma registration, early diagnosis, and prevention. These differences should be acknowledged and understood by physicians, researchers, and all stakeholders involved in improving melanoma care and outcomes, as no one-size-fits-all solution can tackle the melanoma problem in Europe. Instead, there is a need for nuanced strategies, adapted to the heterogeneous national and regional contexts, that would build on European diversity to eliminate the outcome disparities.

Dermoscopic features of basal cell carcinoma and its subtypes: A systematic review

BACKGROUND

Multiple studies have reported on dermoscopic structures in basal cell carcinoma (BCC) and its subtypes, with varying results.

OBJECTIVE

To systematically review the prevalence of dermoscopic structures in BCC and its subtypes.

METHODS

Databases and reference lists were searched for relevant trials according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were assessed for the relative proportion of BCC dermoscopic features. Random-effects models were used to estimate summary effect sizes.

RESULTS

Included were 31 studies consisting of 5950 BCCs. The most common dermoscopic features seen in BCC were arborizing vessels (59%), shiny white structures (49%), and large blue-grey ovoid nests (34%). Arborizing vessels, ulceration, and blue-grey ovoid nests and globules were most common in nodular BCC; short-fine telangiectasia, multiple small erosions, and leaf-like, spoke wheel and concentric structures in superficial BCC; porcelain white areas and arborizing vessels in morpheaform BCC; and arborizing vessels and ulceration in infiltrative BCC.

LIMITATIONS

Studies had significant heterogeneity. Studies reporting BCC histopathologic subtypes did not provide clinical data on pigmentation of lesions.

CONCLUSION

In addition to arborizing vessels, shiny white structures are a common feature of BCC. A constellation of dermoscopic features may aid in differentiating between BCC histopathologic subtypes.

Clinical photography: Attitudes among dental students in two dental institutions

INTRODUCTION

Clinical photography is an important tool in teaching, clinical practice and academia especially for mucosal pathologies. Our aim was to examine differences in attitude towards clinical photography for mucosal pathologies among students.

METHODS

Questionnaires about clinical photography were completed by students in dental teaching hospitals in Birmingham (UK) and in Israel (ISR). The questionnaires focussed on the perceived value of clinical photography for a number of purposes and also explored perceived barriers to clinical photography and technology in general. The two departments have different access to clinical photography; in the United Kingdom a separate dedicated photography unit takes all the photographs, whereas in ISR the clinicians take their own photographs. Pearson Chi-squared tests determined statistical significance between categorical variables (P < 0.05).

RESULTS

Among the 163 respondents, there were no significant differences in the value of photography between countries or genders. The participants felt that the aims of photography included: teaching (99.4%), monitoring premalignancy (97.6%) and clinician communication (95.8%). More than 90% thought photography should be used for dysplasia and erosive lichen planus cases. Respondents from ISR were more in favour of photographing pathologies including simple leukoplakia, reticular lichen planus, vesiculobullous or pigmented lesions (P < 0.001 compared to the UK). Overall, the main reasons for not using photography were time constraints (25.5%) and access (21.8%).

CONCLUSIONS

This study highlights a favourable attitude towards clinical photography for various teaching and clinical indications thereby demonstrating its importance. In order to maximise the benefits of clinical photography, access should be simplified.

Standardization of dermoscopic terminology and basic dermoscopic parameters to evaluate in general dermatology (non-neoplastic dermatoses): an expert consensus on behalf of the International Dermoscopy Society

BACKGROUND

Over the last few years, several articles on dermoscopy of non-neoplastic dermatoses have been published, yet there is poor consistency in the terminology among different studies.

OBJECTIVES

We aimed to standardize the dermoscopic terminology and identify basic parameters to evaluate in non-neoplastic dermatoses through an expert consensus.

METHODS

The modified Delphi method was followed, with two phases: (i) identification of a list of possible items based on a systematic literature review and (ii) selection of parameters by a panel of experts through a three-step iterative procedure (blinded e-mail interaction in rounds 1 and 3 and a face-to-face meeting in round 2). Initial panellists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses.

RESULTS

Twenty-four international experts took part in all rounds of the consensus and 13 further international participants were also involved in round 2. Five standardized basic parameters were identified: (i) vessels (including morphology and distribution); (ii) scales (including colour and distribution); (iii) follicular findings; (iv) 'other structures' (including colour and morphology); and (v) 'specific clues'. For each of them, possible variables were selected, with a total of 31 different subitems reaching agreement at the end of the consensus (all of the 29 proposed initially plus two more added in the course of the consensus procedure).

CONCLUSIONS

This expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This tool, if adopted by clinicians and researchers in this field, is likely to enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology. What's already known about this topic? Over the last few years, several papers have been published attempting to describe the dermoscopic features of non-neoplastic dermatoses, yet there is poor consistency in the terminology among different studies. What does this study add? The present expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This consensus should enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology.

Comparison of the accuracy of human readers versus machine-learning algorithms for pigmented skin lesion classification: an open, web-based, international, diagnostic study

BACKGROUND

Whether machine-learning algorithms can diagnose all pigmented skin lesions as accurately as human experts is unclear. The aim of this study was to compare the diagnostic accuracy of state-of-the-art machine-learning algorithms with human readers for all clinically relevant types of benign and malignant pigmented skin lesions.

METHODS

For this open, web-based, international, diagnostic study, human readers were asked to diagnose dermatoscopic images selected randomly in 30-image batches from a test set of 1511 images. The diagnoses from human readers were compared with those of 139 algorithms created by 77 machine-learning labs, who participated in the International Skin Imaging Collaboration 2018 challenge and received a training set of 10 015 images in advance. The ground truth of each lesion fell into one of seven predefined disease categories: intraepithelial carcinoma including actinic keratoses and Bowen's disease; basal cell carcinoma; benign keratinocytic lesions including solar lentigo, seborrheic keratosis and lichen planus-like keratosis; dermatofibroma; melanoma; melanocytic nevus; and vascular lesions. The two main outcomes were the differences in the number of correct specific diagnoses per batch between all human readers and the top three algorithms, and between human experts and the top three algorithms.

FINDINGS

Between Aug 4, 2018, and Sept 30, 2018, 511 human readers from 63 countries had at least one attempt in the reader study. 283 (55·4%) of 511 human readers were board-certified dermatologists, 118 (23·1%) were dermatology residents, and 83 (16·2%) were general practitioners. When comparing all human readers with all machine-learning algorithms, the algorithms achieved a mean of 2·01 (95% CI 1·97 to 2·04; p<0·0001) more correct diagnoses (17·91 [SD 3·42] vs 19·92 [4·27]). 27 human experts with more than 10 years of experience achieved a mean of 18·78 (SD 3·15) correct answers, compared with 25·43 (1·95) correct answers for the top three machine algorithms (mean difference 6·65, 95% CI 6·06-7·25; p<0·0001). The difference between human experts and the top three algorithms was significantly lower for images in the test set that were collected from sources not included in the training set (human underperformance of 11·4%, 95% CI 9·9-12·9 vs 3·6%, 0·8-6·3; p<0·0001).

INTERPRETATION

State-of-the-art machine-learning classifiers outperformed human experts in the diagnosis of pigmented skin lesions and should have a more important role in clinical practice. However, a possible limitation of these algorithms is their decreased performance for out-of-distribution images, which should be addressed in future research.

FUNDING

None.

The status of dermoscopy in Germany - results of the cross-sectional Pan-Euro-Dermoscopy Study

BACKGROUND

Survey on the current status of dermoscopy in Germany.

METHODS

In the context of a pan-European internet-based study (n = 7,480) conducted by the International Dermoscopy Society, 880 German dermatologists were asked to answer questions with respect to their level of training as well as their use and perceived benefit of dermoscopy.

RESULTS

Seven hundred and sixty-two (86.6 %) participants practiced dermatology in a publicly funded health care setting; 98.4 % used a dermoscope in routine clinical practice. About 93 % (n = 814) stated to have had more than five years of experience in the use of dermoscopy. Dermoscopy was considered useful in the diagnosis of melanoma by 93.6 % (n = 824); for pigmented skin tumors, by 92.4 % (n = 813); in the follow-up of melanocytic lesions, by 88.6 % (n = 780); for non-pigmented lesions, by 71.4 % (n = 628), in the follow-up of non-melanocytic lesions, by 52.7 % (n = 464); and for inflammatory skin lesions, by 28.5 % (n = 251). Overall, 86.5 % (n = 761) of participants felt that - compared to naked-eye examination - dermoscopy increased the number of melanomas diagnosed; 77,7 % (n = 684) considered the number of unnecessary excisions of benign lesions to be decreased. Participants who personally felt that dermoscopy improved their ability to diagnose melanoma were significantly i) younger, ii) had been practicing dermatology for a shorter period of time, iii) were less commonly employed by an university-affiliated dermatology department, iv) were more frequently working in an office-based public health care setting, and v) had more frequently been trained in dermoscopy during their dermatology residency.

CONCLUSIONS

The findings presented herein ought to be integrated into future residency and continuing medical education programs with the challenge to improve dermato-oncological care and to expand the diagnostic spectrum of dermoscopy to include inflammatory skin diseases.

ECCO essential requirements for quality cancer care: Melanoma

BACKGROUND

ECCO essential requirements for quality cancer care (ERQCC) are explanations and descriptions of challenges, organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe.

MELANOMA

ESSENTIAL REQUIREMENTS FOR QUALITY CARE: CONCLUSION: Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality service for melanoma. The ERQCC expert group is aware that it is not possible to propose a 'one size fits all' system for all countries, but urges that access to multidisciplinary teams and specialised treatments is guaranteed to all patients with melanoma.

A survey on the pattern of dermoscopy use among dermatologists in India

INTRODUCTION AND BACKGROUND

Dermoscopy is being increasingly used for improving dermatological diagnosis. Use of dermoscopy in the early recognition of skin malignancies, especially melanoma, is well established. Of late, its use in general clinical dermatology is growing with the recognition of new and specific patterns in conditions such as hair disorders, inflammatory disorders, and infections/infestations. This cross-sectional survey aims to assess the common patterns of dermoscopy use by Indian dermatologists.

METHODS

This was across-sectional survey. An online questionnaire was used to collect data. The questionnaire focused on the frequency of dermoscopy use by Indian dermatologists, reasons for using it or not, and the training they had received on dermoscopy.

RESULTS

Of the total 150 valid responses, eighty two (54.7%) participants reported that they were using dermoscopy routinely in their clinical practice. Lack of familiarity and lack of proper training were the important reasons cited for not using dermoscopy regularly. Among the dermatologists using dermoscopy, consensus on effectiveness was highest for hair disorders.

CONCLUSIONS

Dermoscopy use by dermatologists in India is mainly in the context of inflammatory dermatosis and hair disorders rather than skin tumors. Lack of familiarity with the technique appears to be main factor limiting the use of dermoscopy in India.

LIMITATIONS

Small sample size is the major limitation of this study. It is possible that a large number of dermatologists who do not use dermoscopy might not have responded to the survey, there by affecting the results and their interpretation.

Operable Melanoma: Screening, Prognostication, and Adjuvant and Neoadjuvant Therapy

The importance of reducing the numbers of patients with late-stage melanoma, identifying which patients are most likely to progress, and treating these patients at the earliest possible stage cannot be overemphasized. Improved screening of patients prior to diagnosis has the advantage of identifying early-stage disease that is for the most part treatable by surgical methods. The process of melanoma screening is rapidly evolving through population-based programs, mobile health technologies, and advanced imaging tools. For patients with newly diagnosed melanoma, accurately estimating disease prognosis has important implications for management and follow-up. Prognostic factors are individual host- or tumor-related factors or molecules that correlate with genetic predisposition and clinical course. These include clinical covariates and host and tumor proteomic/genomic markers that allow the prognostic subclassification of patients. Adjuvant therapy for high-risk surgically resected melanoma targets residual micrometastatic disease with the goal of reducing the risk of relapse and mortality. In the United States, three regimens have achieved regulatory approval for adjuvant therapy, including high-dose interferon alpha, pegylated interferon alpha, and ipilimumab at 10 mg/kg. Phase III trials have reported benefits in relapse-free survival (all regimens) and overall survival (high-dose interferon alpha and ipilimumab). The management of locally/regionally advanced melanoma may benefit from neoadjuvant therapy, which is the subject of several ongoing studies. Recent studies have shown promising clinical activity and yielded important biomarker findings and mechanistic insights.

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].