Would dermoscopic photographs helptriage teledermatology consults in the COVID-19 era?

Background: The coronavirus pandemic led to a rapid transition to telemedicine across medical specialties.Dermatologists can utilize digital images to remotely manage skin diseases, including determining the urgency withwhich patients need to be seen in person. Accurately triaging urgent cases can be impacted by imaging modality.Dermoscopy is the examination of the skin with polarized light, which for some providers can increase theirdiagnostic accuracy and confidence in managing potential skin cancers. It has been increasingly viewed as astandard adjunct for examining skin lesions. Dermoscopic photographs have been shown to improve providers'abilities to correctly diagnose telemedicine consults. However, this has only been studied with a limited subset ofskin neoplasms and is limited to a workflow involving a photographer with a dermatoscopic imaging capability. In thepandemic, the ability of patients to access dermoscopy is exceedingly limited. This study aims to assess the impactof dermoscopy on decision-making by dermatologists, including confidence, diagnostic accuracy, and triagingurgency. Our premise is that if dermoscopy is impactful, innovative means to increase accessibility to dermoscopywould be valuable for cancer management during COVID. Methods: Twenty sets of clinical and dermoscopic photographs were selected as representative of commonly seenskin pathologies in our teledermatology consults. Study participants were first shown a clinical photograph andasked to determine their diagnoses, management decisions, level of urgency, and confidence in their triagedecisions. The responses were scaled ranging from non-neoplastic to malignant, 0-100% confidence, and non-urgent (1) to emergent (3), respectively. They were then asked to answer the same questions after viewing theassociated dermoscopic image. Results: Twenty-six physicians participated in the study: 16 dermatology attendings and 10 residents. The majorityreported using dermoscopy in ≥25% of their clinical practice. Fifty-nine percent rated themselves as “somewhatconfident” in their dermoscopic abilities. Providers correctly diagnosed 45.3% of study cases using clinical imagesalone. This increased to 53.6% after viewing the associated dermoscopic images (p=0.02). The greatest increase was for malignant neoplasms (31% vs. 54%, p=0.0007). Dermoscopy significantly reduced triage urgency scores forboth non-neoplastic (mean 1.6 vs. 1.2, p<0.001) and benign neoplastic (mean 1.43 vs. 1.35, p=0.01) pathologies.Dermoscopy significantly increased urgency scores for malignant neoplasms (mean 1.47 vs. 1.64, p=0.01). There was a 7.6% increase in providers' confidence in their management decisions with dermoscopy (p<0.0001). Conclusions: Dermoscopic photographs improve providers' abilities to correctly diagnose and prioritize skinlesions. In the COVID-19 era, innovative means to make dermoscopy available to patients at risk for skin cancerwould be valuable.