Accuracy of teledermatology for pigmented neoplasms.

BACKGROUND: Accurate diagnosis and management of pigmented lesions is critical because of the morbidity and mortality associated with melanoma. OBJECTIVE: We sought to compare accuracy of store-and-forward teledermatology for pigmented neoplasms with standard, in-person clinic dermatology. METHODS: We conducted a repeated measures equivalence trial involving veterans with pigmented skin neoplasms. Each lesion was evaluated by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and a management plan. The primary outcome was aggregated diagnostic accuracy (match of any chosen diagnosis with histopathology). We also compared the severity of inappropriately managed lesions and, for teledermatology, evaluated the incremental change in accuracy when polarized light dermatoscopy or contact immersion dermatoscopy images were viewed. RESULTS: We enrolled 542 patients with pigmented lesions, most were male (96%) and Caucasian (97%). The aggregated diagnostic accuracy rates for teledermatology (macro images, polarized light dermatoscopy, and contact immersion dermatoscopy) were not equivalent (95% confidence interval for difference within +/-10%) and were inferior (95% confidence interval lower bound <10%) to clinic dermatology. In general, the addition of dermatoscopic images did not significantly change teledermatology diagnostic accuracy rates. In contrast to diagnostic accuracy, rates of appropriate management plans for teledermatology were superior and/or equivalent to clinic dermatology (all image types: all lesions, and benign lesions). However, for the subgroup of malignant lesions (n = 124), the rate of appropriate management was significantly worse for teledermatology than for clinic dermatology (all image types). Up to 7 of 36 index melanomas would have been mismanaged via teledermatology. LIMITATIONS: Nondiverse study population and relatively small number of melanomas were limitations. CONCLUSIONS: In general, the diagnostic accuracy of teledermatology was inferior whereas management was equivalent to clinic dermatology. However, for the important subgroup of malignant pigmented lesions, both diagnostic and management accuracy of teledermatology was generally inferior to clinic dermatology and up to 7 of 36 index melanomas would have been mismanaged via teledermatology. Teledermatology and teledermatoscopy should be used with caution for patients with suspected malignant pigmented lesions.

Accuracy of teledermatology for nonpigmented neoplasms.

BACKGROUND: Studies of teledermatology utilizing the standard reference of histopathology are lacking. OBJECTIVE: To compare accuracy of store-and-forward teledermatology for non-pigmented neoplasms with in-person dermatology. METHODS: This study was a repeated-measures equivalence trial involving veterans with non-pigmented skin neoplasms. Each lesion was evaluated by an in-person dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and management plan. The primary outcome was aggregated diagnostic accuracy (percent correct matches of any chosen diagnosis with histopathology). Secondary outcomes included management plan accuracy (percent correct matches with expert panel management plan). Additional analyses included evaluation of the incremental effect of using polarized light dermatoscopy in addition to standard macro images, and evaluating benign and malignant lesion subgroups separately. RESULTS: Most of the 728 participants were male (97.8%) and Caucasian (98.9%). The aggregated diagnostic accuracy (primary outcome) of teledermatology (macro images) was not equivalent (95% confidence interval [CI] for difference within +/-10%) and was inferior (95% CI lower bound <10%) to in-person dermatology for all lesions and the subgroups of benign and malignant lesions. However, management plan accuracy was equivalent. Teledermatology aggregated diagnostic accuracy using polarized light dermatoscopy was significantly better than for macro images alone (P = .0017). The addition of polarized light dermatoscopy showed the same pattern for malignant lesions, but not for benign lesions. Most interestingly, for malignant lesions, the addition of polarized light dermatoscopy yielded equivalent aggregated diagnostic accuracy rates. LIMITATIONS: Non-diverse study population. CONCLUSIONS: Using macro images, the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but accuracy of management plans was equivalent. The addition of polarized light dermatoscopy yielded significantly better aggregated diagnostic accuracy, but management plan accuracy was not significantly improved. For the important subgroup of malignant lesions, the addition of polarized light dermatoscopy yielded equivalent diagnostic accuracy between teledermatologists and clinic dermatologists.

Dermoscopic evaluation of amelanotic and hypomelanotic melanoma.

OBJECTIVE: To determine the predictive dermoscopic features of amelanotic and hypomelanotic melanoma. DESIGN: A total of 105 melanomas (median Breslow thickness, 0.76 mm), 170 benign melanocytic lesions, and 222 nonmelanocytic lesions lacking significant pigment (amelanotic, partially pigmented, and light colored) were imaged using glass-plate dermoscopy devices and scored for 99 dermoscopic features. Diagnostic models were derived from and tested on independent randomly selected lesions. SETTING: Predominantly hospital-based clinics from 5 continents. MAIN OUTCOME MEASURES: Sensitivity, specificity, and odds ratios for individual features and models for the diagnosis of melanoma and malignancy. RESULTS: The most significant negative predictors of melanoma were having multiple (>3) milialike cysts (odds ratio, 0.09; 95% confidence interval, 0.01-0.64), comma vessels with a regular distribution (0.10; 0.01-0.70), comma vessels as the predominant vessel type (0.16; 0.05-0.52), symmetrical pigmentation pattern (0.18; 0.09-0.39), irregular blue-gray globules (0.20; 0.05-0.87), and multiple blue-gray globules (0.28; 0.10-0.81). The most significant positive predictors were having a blue-white veil (odds ratio,13; 95% confidence interval, 3.9-40.0), scarlike depigmentation (4.4; 2.4-8.0), multiple blue-gray dots (3.5; 1.9-6.4), irregularly shaped depigmentation (3.3; 2.0-5.3), irregular brown dots/globules (3.2; 1.8-5.6), 5 to 6 colors (3.2; 1.6-6.3), and predominant central vessels (3.1; 1.6-6.0). A simple model distinguishing melanomas from all nonmelanomas had a sensitivity of 70% and a specificity of 56% in the test set. A model distinguishing all malignant lesions from benign lesions had a sensitivity of 96% and a specificity of 37%. Conclusion Although the diagnostic accuracy of dermoscopy for melanoma lacking significant pigment is inferior to that of more pigmented lesions, features distinguishing the former from benign lesions can be visualized on dermoscopic evaluation.

No nonsense dermoscopy: self-assessment.

This periodic column will help clinicians evaluate their own proficiency and gain new knowledge in the general principles of dermoscopy. To assess diagnostic skills, review questions 1 to 4. Answers and explanations are provided.

The diagnostic performance of expert dermoscopists vs a computer-vision system on small-diameter melanomas.

OBJECTIVE: To evaluate the performance of dermoscopists in diagnosing small pigmented skin lesions (diameter

Nevus type in dermoscopy is related to skin type in white persons.

BACKGROUND: Dermoscopic classification of acquired melanocytic nevi (AMN) is based on the evaluation of 3 main criteria-global pattern, pigment distribution, and color. OBJECTIVE: To determine whether these features are different in AMN in white people with different skin types (STs) according to the Fitzpatrick classification. DESIGN: Digital dermoscopic images of AMN were evaluated, and the correlation of the 3 main dermoscopic criteria with patient ST was analyzed. SETTING: Consecutive patients were recruited from 7 pigmented lesion clinics between June 1, 2004, and June 30, 2005. Patients For each patient, the ST (I [always burns, never tans] to IV [rarely burns, tans with ease]) was scored, and 1 representative AMN (defined as the AMN showing a dermoscopic typology that is repeatedly seen in the same patient) was selected and photographed. MAIN OUTCOME MEASURES: The distribution of the dermoscopic criteria of AMN in patients with different STs was calculated by univariate analysis. Differences in prevalence were tested using the chi(2) test. The correlation between dermoscopic criteria and ST, adjusted for age, sex, and enrolling center, was evaluated by calculating odds ratios and 95% confidence intervals by logistic regression analysis. RESULTS: Of 680 included patients, dermoscopic analysis revealed significant differences in the prevalent nevus pattern in the 4 ST groups. Light brown AMN with central hypopigmentation were associated with ST I, and ST IV was associated with the so-called black nevus (P<.001), typified by reticular pattern, central hyperpigmentation, and dark brown coloration. A significant association was also found between multifocal pattern and ST II and ST III. CONCLUSIONS: The dermoscopic nevus type varies according to different ST in white people. This knowledge may have an effect on obtaining for biopsy lesions that exhibit unusual dermoscopic patterns when patient ST is considered.

Dermoscopy features of melanoma incognito: indications for biopsy.

BACKGROUND: To avoid missing melanoma, the current practice is to biopsy all suggestive skin lesions. Although most cases of melanoma exhibit clinical clues leading to the correct diagnosis, melanoma can mimic benign lesions. Dermoscopy has been shown to increase the diagnostic accuracy of clinically equivocal lesions, but little is known about its ability to detect melanoma in the context of lesions that appear clinically benign. METHODS: We present 7 difficult-to-diagnose melanomas, in which additional clues provided by dermoscopy increased the index of suggestion and led us to perform a biopsy. RESULTS: Our cases highlight the following 7 management rules: 1) Dermoscopy should not be used only for suggestive skin lesions. 2) Biopsy lesions missing clinicodermoscopic correlation. 3) Biopsy lesions with unspecific pigment pattern. 4) Biopsy lesions with spitzoid features. 5) Biopsy lesions with extensive regression features. 6) In patients with multiple nevi, biopsy lesions changing after short-term follow-up. 7) Biopsy pink lesions with an atypical vascular pattern. LIMITATIONS: The reported series of cases is small. Dermoscopy has not been rigorously compared with handheld magnification (as with a x7 loupe). CONCLUSIONS: Dermoscopy can increase the index of suggestion to perform biopsy in difficult-to-diagnose melanomas.

The performance of SolarScan: an automated dermoscopy image analysis instrument for the diagnosis of primary melanoma.

OBJECTIVE: To describe the diagnostic performance of SolarScan (Polartechnics Ltd, Sydney, Australia), an automated instrument for the diagnosis of primary melanoma. DESIGN: Images from a data set of 2430 lesions (382 were melanomas; median Breslow thickness, 0.36 mm) were divided into a training set and an independent test set at a ratio of approximately 2:1. A diagnostic algorithm (absolute diagnosis of melanoma vs benign lesion and estimated probability of melanoma) was developed and its performance described on the test set. High-quality clinical and dermoscopy images with a detailed patient history for 78 lesions (13 of which were melanomas) from the test set were given to various clinicians to compare their diagnostic accuracy with that of SolarScan. SETTING: Seven specialist referral centers and 2 general practice skin cancer clinics from 3 continents. Comparison between clinician diagnosis and SolarScan diagnosis was by 3 dermoscopy experts, 4 dermatologists, 3 trainee dermatologists, and 3 general practitioners. PATIENTS: Images of the melanocytic lesions were obtained from patients who required either excision or digital monitoring to exclude malignancy. MAIN OUTCOME MEASURES: Sensitivity, specificity, the area under the receiver operator characteristic curve, median probability for the diagnosis of melanoma, a direct comparison of SolarScan with diagnoses performed by humans, and interinstrument and intrainstrument reproducibility. RESULTS: The melanocytic-only diagnostic model was highly reproducible in the test set and gave a sensitivity of 91% (95% confidence interval [CI], 86%-96%) and specificity of 68% (95% CI, 64%-72%) for melanoma. SolarScan had comparable or superior sensitivity and specificity (85% vs 65%) compared with those of experts (90% vs 59%), dermatologists (81% vs 60%), trainees (85% vs 36%; P =.06), and general practitioners (62% vs 63%). The intraclass correlation coefficient of intrainstrument repeatability was 0.86 (95% CI, 0.83-0.88), indicating an excellent repeatability. There was no significant interinstrument variation (P = .80). CONCLUSIONS: SolarScan is a robust diagnostic instrument for pigmented or partially pigmented melanocytic lesions of the skin. Preliminary data suggest that its performance is comparable or superior to that of a range of clinician groups. However, these findings should be confirmed in a formal clinical trial.

Eccrine porocarcinoma arising in a seborrheic keratosis evaluated with dermoscopy and treated with Mohs' technique.

A 78-year-old white woman returned for a routine 6-month skin cancer examination. She had a history of actinic keratosis and multiple basal cell carcinomas. She had no personal or family history of dysplastic nevi or melanoma. The patient was asymptomatic and unaware of any new or changing skin lesions. The patient had multiple lentigines, hemangiomas, and actinic and seborrheic keratoses on all sun-exposed areas. There were no less than 10 seborrheic keratoses on the right mid-back, and one was found to have a 1-cm, reddish nodule asymmetrically located within it (Figs 1 and 2). A clear papule on the left preauricular area was found on biopsy to be a basal cell carcinoma. The nodule on the back was still present 1 month later and it was felt that further evaluation was indicated. As melanoma has been reported to develop in seborrheic keratoses, we decided to examine the lesion using digital dermoscopy. With digital dermoscopy, a well-demarcated reddish nodule was asymmetrically located within a brown lesion. It blanched significantly with pressure. Within the nodule, there were dotted and irregular linear vessels (atypical vascular pattern; also known as polymorphous vascular pattern) and regular-appearing brown dots. Surrounding the reddish nodule, there were pale and pigmented, comedo-like openings, fissures, and ridges (brain-like appearance). Some of the follicular openings appeared to be within the wall of the nodule (Figs 3 and 4). Comedo-like openings, fissures, and ridges are primary dermoscopic criteria for the diagnosis of a seborrheic keratosis; however, the vascular pattern seen has not been reported in seborrheic keratosis. Due to the patient's age and the rarity of significant pathology arising in a seborrheic keratosis, a shave biopsy was performed. To our surprise, the specimen was interpreted by an experienced dermatopathologist as a well-differentiated eccrine porocarcinoma. Due to the high local recurrence rate and metastatic potential of this carcinoma, the patient was referred for Mohs' surgery. Both the basal cell carcinoma and the eccrine porocarcinoma were excised in one stage. A metastatic work-up was negative and the patient appears to be doing well.

Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet.

BACKGROUND: There is a need for better standardization of the dermoscopic terminology in assessing pigmented skin lesions. OBJECTIVE: The virtual Consensus Net Meeting on Dermoscopy was organized to investigate reproducibility and validity of the various features and diagnostic algorithms. METHODS: Dermoscopic images of 108 lesions were evaluated via the Internet by 40 experienced dermoscopists using a 2-step diagnostic procedure. The first-step algorithm distinguished melanocytic versus nonmelanocytic lesions. The second step in the diagnostic procedure used 4 algorithms (pattern analysis, ABCD rule, Menzies method, and 7-point checklist) to distinguish melanoma versus benign melanocytic lesions. kappa Values, log odds ratios, sensitivity, specificity, and positive likelihood ratios were estimated for all diagnostic algorithms and dermoscopic features. RESULTS: Interobserver agreement was fair to good for all diagnostic methods, but it was poor for the majority of dermoscopic criteria. Intraobserver agreement was good to excellent for all algorithms and features considered. Pattern analysis allowed the best diagnostic performance (positive likelihood ratio: 5.1), whereas alternative algorithms revealed comparable sensitivity but less specificity. Interobserver agreement on management decisions made by dermoscopy was fairly good (mean kappa value: 0.53). CONCLUSION: The virtual Consensus Net Meeting on Dermoscopy represents a valid tool for better standardization of the dermoscopic terminology and, moreover, opens up a new territory for diagnosing and managing pigmented skin lesions.