Dermoscopy: not just for dermatologists

The Prevalence of Dermoscopy Use Among Dermatology Residents in Riyadh, Saudi Arabia: Cross-Sectional Study

Background

Dermoscopy is a noninvasive technology used to examine the skin's invisible microstructures in dermatological practice and is gaining prominence as a crucial tool. Dermoscopy is an evidence-based practice used to enhance the early detection of skin malignancies and to help distinguish between various skin conditions, including pigmented and nonpigmented skin malignancies. Currently, the vast majority of global guidelines for skin cancer recommend dermoscopy as a critical component. Dermoscopy use is increasing worldwide, but to date, no study has documented the attitudes toward and use of dermoscopy among future dermatologists in Saudi Arabia.

Objective

We aimed to determine the proportion of dermatology residents in Riyadh who use dermoscopy in their clinical practice; identify factors influencing the use of dermoscopy, such as availability of equipment, training, and the perceived importance of dermoscopy in clinical practice; explore barriers to dermoscopy use, including the lack of access to necessary resources (eg, dermoscopes) and insufficient training; and provide insights into the adoption and integration of dermoscopy into dermatology training and clinical practice in Saudi Arabia.

Methods

In January 2024, a validated and published questionnaire was modified to meet research requirements and was sent to all registered dermatology residents in the The Saudi Board of Dermatology and Venereology Program.

Results

In total, 63 dermatology residents in Riyadh, Saudi Arabia, completed the web-based questionnaire (response rate=87.5%). The sample was predominantly female (n=34, 54.0%), with the majority (n=53, 84.1%) aged between 26 and 30 years. A notable proportion of participants (n=22, 34.9%) were in their final year of residency. Over half of the participants (n=34, 54.0%) owned a dermoscope, and a substantial number of them (n=23, 36.5%) reported conducting 21-30 clinic consultations per month on average. More than half of the participants (n=36, 57.1%) had received dermoscopy training, and 16 (36.4%) had used dermoscopy for 2 years. Additionally, most participants (n=20, 45.5%) had used nonpolarized immersion-contact dermoscopy, while 19 (43.2%) had used polarized light dermoscopy. Furthermore, the majority (n=22, 50.0%) used dermoscopy in fewer than 10% of cases involving patients with inflammatory skin lesions. Statistical analysis revealed significant associations between the participants' ages (P=.003), residency levels (P=.001), and practice centers and the use of dermoscopy (P=.004).

Conclusions

Dermoscopy has been widely adopted by dermatology residents in their daily clinical practice due to its benefits in early detection and diagnosis of skin diseases. However, the overall extent of dermoscopy use within the dermatology community remains unclear, highlighting the need for further education. In Saudi Arabia, the key factors influencing dermoscopy use include residents' ages, residency levels, and practice centers. Younger dermatologists have expressed strong interest in improving their dermoscopy knowledge and skills. Expanding access to dermoscopy equipment and providing training during residency could further promote its use across the country.

Impact of Clinical Information on Melanocytic Skin Lesion Pathology Diagnosis: A Scoping Review

Importance

There is poor accuracy and reproducibility for the histopathologic diagnosis of melanocytic skin lesions, and the provision of clinical information may improve this.

Objective

To examine the impact of clinical information on the histopathologic diagnosis of melanocytic skin lesions.

Evidence Review

PubMed, Embase, and Cochrane Library were searched for new records published from January 2018 to January 2024. References included in the 2018 Cancer Council Australia evidence review were also screened, and forward and backward citation searches were conducted.

Findings

From 2224 records screened, 162 full-text studies were assessed, and 7 studies were included. Studies included pathologists from Austria, Germany, the US, Italy, the UK, and Australia. Patient populations had a mean age of 43 to 55 years and a proportion of female participants of 23% to 63%. The risk of bias assessment demonstrated that all studies had domains at unclear or high risk of bias. Clinical images increased diagnostic certainty (3 studies) and agreement between pathologists (2 studies) led to diagnostic upgrades in 7.6% to 16.7% of interpretations. Clinical diagnosis on the pathology requisition form reduced the odds of missing a melanoma with progression (1 study), while more clinical elements on the form correlated with higher re-excision rates (1 study). Among patients with distant metastases on long-term follow-up, a prior consensus diagnosis of melanoma was established on histopathology alone.

Conclusions and Relevance

Providing clinical information to pathologists may improve diagnostic confidence and interobserver agreement and result in upgrading of the histopathologic diagnosis. While providing the clinical diagnosis may prevent missing a progressive melanoma, more research is needed to determine the appropriateness of histopathology upgrading when clinical images are provided and the impacts on patient outcomes.

Comparison of Ophthalmologists versus Dermatologists for the Diagnosis and Management of Periorbital Atypical Pigmented Skin Lesions

Background/Objectives: Lentigo maligna (LM) and lentigo maligna melanoma (LMM) are significant subtypes of melanoma, with an annual incidence of 1.37 per 100,000 people in the U.S. These skin tumors, often found in photo-exposed areas such as the face, are frequently misdiagnosed, leading to delayed treatment or unnecessary excisions, especially in the elderly. Facial melanocytic skin tumors (lentigo maligna-LM/lentigo maligna melanoma-LMM) and their simulators (solar lentigo, pigmented actinic keratosis, seborrheic keratosis and lichen planus-like keratosis) often affect the periocular region. Thus, their diagnosis and management can involve different medical figures, mainly dermatologists and ophthalmologists. This study aimed to evaluate the ability of ophthalmologists to diagnose and manage pigmented skin lesions of the periorbital area. Methods: A multicentric, retrospective, cross-sectional study on a dataset of 79 periorbital pigmented skin lesions with both clinical and dermoscopic images was selected. The images were reviewed by six ophthalmologists and two dermatologists. Descriptive statistics were carried out, and the accuracy, sensitivity, and specificity, with their 95% confidence interval (95% CI), were estimated. Results: Ophthalmologists achieved a diagnostic accuracy of 63.50% (95% CI: 58.99-67.85%), while dermatologists achieved 66.50% (95% CI: 58.5-73.8). The sensitivity was lower for ophthalmologists in respect to dermatologists, 33.3% vs. 46.9%, respectively. Concerning the case difficulty rating, ophthalmologists rated as "difficult" 84% of cases, while for dermatologists, it was about 30%. Management was also consistently different, with a "biopsy" decision being suggested in 25.5% of malignant lesions by ophthalmologists compared with 50% of dermatologists. Conclusions: Ophthalmologists revealed a good diagnostic potential in the identification of periorbital LMs/LMMs. Given progressive population ageing and the parallel increase in facial/periorbital skin tumors, the opportunity to train new generations of ophthalmologists in the early diagnosis of these neoformations should be considered in the next future, also taking into account the surgical difficulty/complexity of this peculiar facial area.

Dermoscopy can be safely and reliably used in ophthalmology

Objective

To determine if dermoscopy, a technique widely utilized in dermatology for improved diagnosis of skin lesions, can be used comfortably for evaluating periorbital, eyelid, and conjunctival lesions.

Design

Proof-of-concept study in which a technique for performing dermoscopy near the eye was developed, related educational material was prepared, and a protocol for dermoscopic image capture was created.

Methods

Technicians used the developed materials to learn to take high-quality pictures with a 10x dermoscope attached to a standard cell phone camera. The images were assessed for diagnostic utility by an oculoplastic surgeon and two dermatologists.

Participants

115 patients recruited from ophthalmology clinics from July 2021 to April 2023 were photographed, yielding 129 lesions with high-quality dermoscopic images as assessed by an oculoplastic surgeon and two dermatologists.

Results

Technicians reported a significant increase in confidence (measured on a 1-10 scale) with dermoscopy after training (pre-instruction mean = 1.72, median = 1, mode = 1, IQR = 1.25 vs mean = 7.69, median = 7.75, mode = 7 and 8, IQR = 1.5 post-instruction. Wilcoxon rank sum test with continuity correction, W = 0, p < 0.001, paired t = 13.95, p < 0.0001). Incorporating a contact plate with a 4 × 4mm reticule on the dermoscope aided in photographing ocular and periocular lesions.

Conclusion

Medical support staff in eye-care offices can be taught to use dermoscopes to capture high-quality images of periorbital, eyelid, and conjunctival lesions. Dermoscopy illuminates diagnostic features of lesions and thus offers a new avenue to improve decision-making in ophthalmology. Dermoscopy can be incorporated into telemedicine evaluations by ophthalmologists, oculoplastic surgeons, or affiliated dermatologists for triage of or rendering advice to patients and for planning of surgery if needed.

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.

Handheld cross-polarised microscope for imaging individual pigmented cells in human skin in vivo

We present the development of a simple, handheld cross-polarised microscope (CPM) and demonstration of imaging individual pigmented cells in human skin in vivo. In the CPM device, the cross-polarised detection approach is used to reduce the specular reflection from the skin surface and preferentially detect multiply-scattered light. The multiply-scattered light works as back illumination from within the tissue towards the skin surface, and superficial pigment such as intraepidermal melanin absorbs some spectral bands of the multiply-scattered light and cast coloured shadows. Since the light that interacted with the superficial pigment only needs to travel a short distance before it exits the skin surface, microscopic details of the pigment can be preserved. The CPM device uses a water-immersion objective lens with a high numerical aperture to image the microscopic details with minimal spherical aberrations and a small depth of focus. Preliminary results from a pilot study of imaging skin lesions in vivo showed that the CPM device could reveal three-dimensional distribution of pigmented cells and intracellular distribution of pigment. Co-registered CPM and reflectance confocal microscopy images showed good correspondence between dark, brown cells in CPM images and bright, melanin-containing cells in reflectance confocal microscopy images.

Leveraging Machine Learning for Accurate Detection and Diagnosis of Melanoma and Nevi: An Interdisciplinary Study in Dermatology

This study explores the application of machine learning and deep learning algorithms to facilitate the accurate diagnosis of melanoma, a type of malignant skin cancer, and benign nevi. Leveraging a dataset of 793 dermatological images from the Kaggle online platform (Google LLC, Mountain View, California, United States), we developed a model that can accurately differentiate between these lesions based on their distinctive features. The dataset was divided into training (80%), validation (10%), and testing (10%) sets to optimize model performance and ensure its generalizability. Our findings demonstrate the potential of machine learning algorithms in enhancing the efficiency and accuracy of melanoma and nevi detection, with the developed model exhibiting robust performance metrics. Nonetheless, limitations exist due to the potential lack of comprehensive representation of melanoma and nevi cases in the dataset, and variations in image quality and acquisition methods, which may influence the model's performance in real-world clinical settings. Therefore, further research, validation studies, and integration into clinical practice are necessary to ensure the reliability and generalizability of these models. This study underscores the promise of artificial intelligence in advancing dermatologic diagnostics, aiming to improve patient outcomes by supporting early detection and treatment initiation for melanoma.

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.

Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care

BACKGROUND

Primary care providers (PCPs) frequently address dermatologic concerns and perform skin examinations during clinical encounters. For PCPs who evaluate concerning skin lesions, dermoscopy (a noninvasive skin visualization technique) has been shown to increase the sensitivity for skin cancer diagnosis compared with unassisted clinical examinations. Because no formal consensus existed on the fundamental knowledge and skills that PCPs should have with respect to dermoscopy for skin cancer detection, the objective of this study was to develop an expert consensus statement on proficiency standards for PCPs learning or using dermoscopy.

METHODS

A 2-phase modified Delphi method was used to develop 2 proficiency standards. In the study's first phase, a focus group of PCPs and dermatologists generated a list of dermoscopic diagnoses and associated features. In the second phase, a larger panel evaluated the proposed list and determined whether each diagnosis was reflective of a foundational or intermediate proficiency or neither.

RESULTS

Of the 35 initial panelists, 5 PCPs were lost to follow-up or withdrew; 30 completed the fifth and last round. The final consensus-based list contained 39 dermoscopic diagnoses and associated features.

CONCLUSIONS

This consensus statement will inform the development of PCP-targeted dermoscopy training initiatives designed to support early cancer detection.

Dermoscopy for the Identification of Amelanotic Acral Melanoma

Acral lentiginous melanoma is commonly misdiagnosed, and when detected late it portends a poor prognosis. Acral lentiginous melanoma can be mistaken for verruca, pyogenic granuloma, poroma, an ulcer, or other benign skin conditions. Patients with acral skin growths often present initially to a podiatric physician or their primary care physician. It is at this point when the growth is triaged as benign or potentially malignant. Dermoscopy aids in this decision making. Historically, dermoscopy training has been geared toward dermatologists, but there is increasing recognition of the need for dermoscopy training in primary care and podiatric medicine. Dermoscopy is particularly helpful in pink (amelanotic) growths, which can lack the traditional clinical findings of melanoma. A literature review of acral melanoma and dermoscopy was performed in PubMed. We also describe a case of amelanotic acral melanoma in a 58-year-old with a rapidly enlarging painful mass on her heel. The lesion was initially thought to be a pyogenic granuloma and was treated with debridement (curettage). She was ultimately seen in the dermatology clinic, and the findings under dermoscopy were worrisome for amelanotic melanoma. Biopsy confirmed the diagnosis. The cancer metastasized, and the patient died less than 2 years later.

Evaluation of Dermoscopic Patterns of Vesiculobullous Disorders

Background:

Clinical diagnosis of vesiculobullous disorders (VBD) is not always straightforward. It is a challenge for a dermatologist to make the right diagnosis noninvasively in a short time.

Objective:

To evaluate dermoscopic patterns associated with vesiculobullous disorders.

Methods:

A total of 230 patients, irrespective of age and gender, with a history and clinical presentation suggestive of VBD (including primarily infectious, inflammatory, genetic, antibody-mediated, mechanical, environmental, metabolic, and drug-related) were recruited into the study. Patients with secondarily infected lesions were excluded. Dermoscopic examination along with Tzanck smear/skin biopsy smear test was performed on the most representative lesions. Data were compiled and statistically analyzed using SPSS version 21.0.

Results:

Lesions with erythematous (vascular) and yellowish (serum) translucent background with regular margins were seen in most of the VBD studied. Chickenpox (CP) and herpes zoster (HZ) lesions evolved with the progress of their clinical stages. Follicular and eccrine openings were commonly seen, but the pigmentation around them was specific to pemphigus vulgaris. A distorted pigment network was noted in bullous pemphigoid. White rosettes (keratin blockage) were characteristic of epidermolysis bullosa, Wickham striae (orthokeratosis) of lichen planus, and crumpled fabric appearance (flaccidity) of Hailey-Hailey disease. Globules/dots (microvesicles) of different colors were also seen in various VBD. Blue/black color usually corresponded to retained melanin.

Conclusion:

Some dermoscopic patterns are observed consistently with certain diseases, and these can be used for their diagnosis, complementary to histopathological examination.

Teaching Skin Cancer Detection to Medical Students Using a Dermoscopic Algorithm

Introduction

Early detection of melanoma skin cancer improves survival rates. Training family physicians in dermoscopy with the triage amalgamated dermoscopic algorithm (TADA) has high sensitivity and specificity for identifying malignant skin neoplasms. In this study we evaluated the effectiveness of TADA training among medical students, compared with practicing clinicians.

Methods

We incorporated the TADA framework into 90-minute workshops that taught dermoscopy to family physicians, primary care residents, and first- and second-year medical students. The workshop reviewed the clinical and dermoscopic features of benign and malignant skin lesions and included a hands-on interactive session using a dermatoscope. All participants took a 30-image pretest and a different 30-image posttest.

Results

Forty-six attending physicians, 25 residents, and 48 medical students participated in the workshop. Mean pretest scores were 20.1, 20.3, and 15.8 for attending physicians, resident physicians and students, respectively (P<.001); mean posttest scores were 24.5, 25.9, and 24.1, respectively (P=.11). Pre/posttest score differences were significant ( P<.001) for all groups. The medical students showed the most gain in their pretest and posttest scores.

Conclusion

After short dermoscopy workshop, medical students perform as well as trained physicians in identifying images of malignant skin lesions. Dermoscopy training may be a valuable addition to the medical school curriculum as this skill can be used by primary care physicians as well as multiple specialists including dermatologists, gynecologists, otolaryngologists, plastic surgeons, and ophthalmologists, who often encounter patients with concerning skin lesions.