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Clinical Review

Dermoscopy for melanoma
detection in family practice
Andrea Herschorn MD CCFP

Abstract
Objective  To assess the diagnostic accuracy and clinical utility of dermoscopy for melanoma detection in family
practice.
Quality of evidence  Ovid MEDLINE (1946 to June 2011), EMBASE, PubMed, and Cochrane databases were searched
using the following terms: dermoscopy, dermatoscopy, epiluminescence microscopy, family practice, general practice,
primary health care, melanoma, skin neoplasms, and pigmented nevus. To be included, studies had to be primary
research articles with family physicians as the subjects and dermoscopy training and use as the intervention. Four
papers met all inclusion criteria and provided level I evidence according to the Canadian Task Force on Preventive
Health Care definition.
Main message  Among family physicians, dermoscopy has higher sensitivity for melanoma detection than naked-
eye examination with generally no decrease in specificity. Dermoscopy also helps to increase family physicians’
confidence in their preliminary diagnosis of lesions. When using dermoscopy, compared with naked-eye examination,
there is a higher likelihood that a lesion assessed as being malignant is in fact malignant and that a lesion assessed
as being benign is in fact benign.
Conclusion  Dermoscopy has been shown to be a useful and fairly inexpensive tool for melanoma detection in
family practice. This technique can increase family physicians’ confidence in their referral accuracy to dermatologists
and can assist in decreasing unnecessary biopsies. Dermoscopy might be especially useful in examining patients at
high risk of melanoma, as the current Canadian clinical practice guideline recommends yearly screening in these
individuals.

T
he incidence of malignant melanoma in Canada has increased substantially over the past several decades, espe-
cially for men.1 In 2010, melanoma was estimated to rank seventh in cancer incidence in men and eighth in
women.2 Approximately 3% (5200) of all new cancer cases and 1.2% (920) of cancer deaths were due to melan-
oma. Early detection and excision of the lesion is the most effective treatment to prevent metastatic disease and to
increase survival.3 Breslow thickness, which is a measure of tumour thickness and depth of invasion, is one of the
most important prognostic factors for mortality: the earlier the lesion is detected, the higher the chance of survival.4
Currently among family physicians naked-eye examination using the ABCDE criteria is widely used: the physician
looks at the simple morphologic appearance of the lesion, assessing for asymmetry, border irregularity, colour varie-
gation, diameter greater than 6 mm, and evolution in appearance,5 although the evolution (E) criterion is not always
included in the assessment. Sensitivity and specificity vary depending on how many of the features are present.
Sensitivity and specificity have been shown to range from 43% and 99.6%, respectively, with all 5 criteria present, to
97.3% and 36%, respectively, when 1 criterion is present.6 The group of
physicians that originally developed these criteria did so for the pur- KEY POINTS  Dermoscopy is a helpful and
pose of helping nondermatologists to differentiate between common inexpensive tool that can be used in daily
nevi and melanomas; they were not intended for the detection of all family practice. Family physicians can use
malignant lesions.6 dermoscopic algorithms comfortably after a
Another clinical approach that is increasing in popularity is termed short training program. Dermoscopy improves
the “ugly duckling sign.” It is based on the premise that nevi on an family physicians’ diagnostic accuracy and
individual’s skin tend to resemble one another, and that the malignant confidence in identifying malignant lesions.
lesion is identifiable because it differs from its neighbours.6,7 Scope et This technique can help to decrease biopsy
rates of benign lesions and unnecessary
referrals to dermatologists.
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La traduction en français de cet article se trouve à www.cfp.ca dans la
table des matières du numéro de juillet 2012 à la page e372.
This article has been peer reviewed.
Can Fam Physician 2012;58:740-5

740  Canadian Family Physician • Le Médecin de famille canadien | Vol 58:  JuLY • JUILLET 2012

the were then randomly assigned to examine skin lesions Vol 58:  JuLY • JUILLET 2012 | Canadian Family Physician • Le Médecin de famille canadien  741 . dermoscopy. EMBASE.6. Dermoscopy for melanoma detection in family practice | Clinical Review al8 demonstrated that the ugly duckling sign is at least benign-to-malignant ratio significantly decreased from 85% sensitive. or oil epiluminescence microscopy) is a technique common algorithms are pattern analysis. 9 Thus.22-25 A total of 4 studies the naked eye alone.3:1 (P = . 13 A randomized trial of dermatologists Main message trained in dermoscopy revealed a 42% reduction in the Study characteristics. Quality of evidence nostic accuracy of naked-eye examination with that of Ovid MEDLINE (1946 to June 2011). review aims to answer these 2 important questions.10 with untrained dermatologists. Articles assessing the use of dermoscopy cious lesions using naked-eye examination alone com. no decrease in specificity. and diagnostic accuracy for detecting malignant reflection. the research lesions seen in everyday practice.19 ally 10-fold magnification) to visualize a skin lesion in A consensus meeting among dermatologists determined depth. even when used by nondermatologists. and the Menzies method. refraction. and diffraction. Results revealed a sensitivity (percentage and Cochrane databases were searched using the fol- of melanomas correctly diagnosed) of 71% in naked-eye lowing terms: dermoscopy. Dermoscopic algorithms When using a dermatoscope. After the physician examines a suspicious Dermoscopy has been shown to be a beneficial tool in lesion with his or her naked-eye. 18:1 to 4. Studies were included if they were pri- number of misdiagnosed nonmelanomas.18. it is important to have an What is dermoscopy? algorithm with which to analyze the lesion to help differ- Dermoscopy (also dermatoscopy. This enabled the viewer checklist algorithm has recently been developed that to detect structures and details below the epidermis that showed high sensitivity and reproducibility when used could not be seen by the naked eye. speci- alcohol applied to the lesion in order to decrease light ficity. The cost of a copy help family doctors improve their diagnostic accur- dermatoscope can range from a few hundred dollars to acy when examining pigmented lesions? Is dermoscopy more than a thousand dollars depending on the manu. entiate between malignant and benign nevi. and pig- improved diagnostic accuracy without increasing the mented nevus. However. However. dermatoscopy. but they unnecessary biopsies. family practice. the ABCD that involves using a hand-held light magnifier (usu.04). Two of the papers were randomized con- of a retrospective study of pigmented lesion excisions trolled trials (RCTs). Thus. The new magnifi. see many fewer malignant lesions daily than dermatolo.22 over a period of time before and after dermoscopy primary care physicians were trained in dermoscopy and use was implemented among dermatologists. a suitable technique to be used in family practice? This facturer and model. the 7-point checklist. pared with naked-eye examination in combination with dermoscopy. The 4 most copy.15 The benign-to-malignant ratio Research has shown that the accuracy of detecting for physicians who did not use dermoscopy did not melanoma is proportional to the number of malignant change significantly (12:1 to 14:1).12 There was escence microscopy. rules. In the study by Argenziano et al. can dermos- then used to obtain a closer. and to make the melanoma versus benign lesions. What if they are missing some melanomas? The on formal training and experience with the device. melanoma. epilumin- examination and 90% using dermoscopy. suggesting that dermoscopy primary health care.20 A simplified 3-point epidermis appear translucent. skin neoplasms.16 overlap in features between malignant melanomas and Studies have shown that dermatologists with formal benign nevi is the basis of the dilemma in melanoma training and at least 3 years of experience in dermos- detection. among dermatologists were not included.21 ers are designed using cross-polarized light filters thus replacing the need for oil or alcohol to be applied to the Applicability to family practice skin surface. A recent meta-analysis of studies done primarily with dermatologists in a clinical setting compared the diag. vention. the effectiveness of dermoscopy depends gists do. by newly trained dermoscopy users.  The main characteristics of the number of unnecessary biopsies compared with using studies are presented in Table 1.14 This is similar to the findings met all criteria. PubMed. detailed look. Is there a better way to detect melanomas copy have higher melanoma detection rates compared and to reduce the number of unnecessary biopsies?6. the dermatoscope is clinical dermatology practice.17 One technique being used by dermatologists to address this problem since the 1990s is dermoscopy. general practice. this poses shows that dermoscopy improves the detection rate a problem: family doctors are expected to detect the of melanoma in addition to decreasing the number of abnormal lesions as the first-line physicians. surface micros.11 The early magnifiers required the use of oil or that pattern analysis had the highest sensitivity. mary research articles with family physicians as the One way to determine if dermoscopy is applicable subjects and dermoscopy training and use as the inter- to clinical practice is to assess excision rates of suspi.

all at × 10 magnification method. The studies used different dermoscopy algorithms: the bination with dermoscopy.23 family physicians were assigned to either a surface al. ies used referral to dermatology experts in addition to copy. In the study by Westerhoff et 3-point checklist was used in the paper by Argenziano et al. all family physicians were trained in dermos. in the studies by Westerhoff et and counterbalance technique. by Westerhoff et al23 and Menzies et al. However.24 The Westerhoff et al23 study confirmed ary diagnosis and management plan (biopsy or referral). they were assess dermoscopic images of the same lesions using the well executed.22 and the Menzies method26 was used in the papers microscopy education intervention or a control group. biopsies of nonusers criteria for suspicious lesions BCC and SCC Westerhoff et al23 RCT Primary care Clinical photographs Not specified Menzies Lesions physicians. Using a within-subjects design clinical practice. and pattern analysis. each group assessed the al23 and Dolianitis et al. SCC—squamous cell carcinoma. ABCD rules. the Menzies method. the participants were family phys- to learn written and computer-based educational materi. examined by melanoma checklist dermoscopy dermoscopy dermatoscope and clinical experts. The 2 clinical stud- In this study. diagnosis. nonmelanoma dermoscopy ABCD rule. physicians in the intervention groups were trained 24 Dolianitis et al. a time. domization. The study by Dolianitis et al25 used lesions and recorded a subsequent diagnosis and man. rithms. Participants were required In 3 of the studies. Dolianitis et al25 used a within-subjects one of the author’s photograph collections.23 The paper by al. study by Dolianitis et al25 used 61 medical practitioners. any hand-held dermatoscope. copy and 35 of whom (57%) were general practitioners. but in differing orders. In all papers. allowing for paired analysis. Blinding was not feasible as physicians used either naked- In the studies by Argenziano et al22 and Menzies et eye or dermoscopy to assess the lesions. the lesion diagnoses with excisional biopsy and histo- The physicians then performed dermoscopy on the same pathologic diagnosis. 742  Canadian Family Physician • Le Médecin de famille canadien | Vol 58:  JuLY • JUILLET 2012 . images of known melanomas and nonmelanomas from agement plan. dermoscopy dermatoscope experts. participants were randomly assigned to The 2 RCTs qualify as level I evidence. the images were graphs of pigmented lesions and did not learn to use the in different random order in each test set. lesions nonusers pattern analysis BCC—basal cell carcinoma. and surface method histopathologically dermoscopy microscopic diagnosed nonusers photographs at × 10 magnification using oil Menzies et al24 Sequential Primary care Patients in clinic Not specified Menzies Evaluated by intervention physicians. icians with no previous training in dermoscopy. 4 different algorithms in different orders. RCT—randomized controlled trial. which simulates real participants to 1 of 4 groups. examined by method dermoscopy trial of within. the physicians examined patients’ skin excisional biopsies as the criterion standard for lesion lesions with the naked eye only and recorded a prelimin. the using within-lesion controls. biopsies of lesion controls nonusers suspicious lesions Dolianitis et al25 Within-subjects Most were Clinical macroscopic Not specified 7-point Images from a design using primary care photographs and checklist. This might not be as generaliz. They were then shown macroscopic images and all of whom were assessed to be non-experts in dermos- asked to identify the melanomas and nonmelanomas.25 although not an RCT. randomly allocated to use a hand-held dermatoscope. design using counterbalance.22-24 The als on melanoma and 4 different dermoscopy algo. physician dropouts were reported and occurred before ran- able to clinical practice but it is still valuable training.Clinical Review | Dermoscopy for melanoma detection in family practice with either the naked eye alone or the naked eye in com.22. photograph bank counterbalance physicians dermoscopic images Menzies of melanoma and technique (35/61).25 physicians were trained to use a same test set of images using 1 dermoscopic algorithm at dermoscopy algorithm while examining magnified photo. using random assignment of participants.22. In addition. Afterward.24 Dolianitis et Menzies et al24 studied a sequential intervention trial al25 used the 7-point checklist. Study characteristics Physician Naked-eye Dermoscopy Paper Study type background SOURCE OF LESIONS criteria Algorithm Reference test Argenziano et al22 RCT Primary care Patients in clinic ABCD rule for 3-point Evaluated by physicians. The sequential intervention trial by Menzies et Table 1. Subsequently.

22-25 dermoscopy. POSITIVE PREDICTIVE NEGATIVE PREDICTIVE Sensitivity.5) clinical photographs (75. According to improvement in the sensitivity of dermoscopic exam- the Canadian Task Force on Preventive Health Care.006).2) 34 (9.1) vs 53. and basal cell carcinoma) scopic imaging to capture a photograph of the lesion were included in the analysis. P < .5 53. confidence in the diagnosis of true nonmelanoma using copy arm compared with the naked-eye examination arm (79.22-24 This suggests that physicians correctly alone or all malignant lesions) ranged from 37.0) cant improvement was seen in the control group (54.8.25 Melanoma using dermoscopy compared with naked-eye examina- prevalence ranged from 0. ies to 50% in the image-based studies (Table 3).179) and for melanoma dence supporting the use of dermoscopy in family practice. of All Malignant. melanoma and nonmelanoma pigmented the confidence of physicians’ diagnoses of true melanoma lesions were differentiated in the analysis.6 mm (or in situ melanoma).1% to 84. demonstrates diagnostic algorithms compared with clinical examina- findings similar to the papers using random assignment. % VALUE.7 94.2% vs 54.4% in naked- papers reported a median Breslow thickness of 0. Menzies et al24 found a non-significant before the physicians examined any lesions.7 NA NA NA NA method • 7-point 60. all malignant tumours (melanoma.8% Menzies et al24 374    42 (11.4 85.014.5%. P = . microscopic images as a new tool. P = . alone (53.2 71.5 to eye examination compared with 71. Westerhoff et al 23 100   53 (53.001).9 84.1%. Further.002). malignant lesions (5% vs 40%. P < .7%.6 89.23.0 NA NA NA NA checklist • ABCD rule 60.0 55. down of melanoma only in 1 study.9% vs 62. % Specificity.4 80. 22. Melanoma.002).9%.0%.5%.8 98.0)   50 (50. had the added option of using sequential digital dermo- squamous cell carcinoma.0 92.9 81.22-25 In both studies in pared with naked-eye examination when the physician the clinical setting. Menzies et Argenziano et al22 demonstrated a significantly higher al24 found a significant improvement in the physicians’ sensitivity for detecting malignant lesions in the dermos.22-25 All Specificity ranged from 71.6 75. P = .5% vs 40. and 71.0 25. % STUDY LESIONS Naked Eye Dermoscopy Naked Eye Dermoscopy Naked Eye Dermoscopy Naked Eye Dermoscopy Argenziano et al22 All malignant 54.0 91. No signifi.9 77.24 although using a weaker methodology.24 In the papers Importantly.3 16.5 85.7 34.001).6 89. STUDY TOTAL No. the ination compared with naked-eye examination for all recommendations from these papers constitute level I evi. Types of lesions assessed demonstrated that after skin surface microscopy train. dropouts were again reported and occurred vs 60.6 85.9 NA NA NA NA NA NA only Menzies et al24 All malignant 40.5% and 9% in the clinical stud. the sensitivity for detection of all malignant lesions and for detection of Comparative test performance. with the Menzies method performing the best (84. Further.1 79. with a separate break. Main statistical results of all studies: Boldface indicates a significant difference (P < .8 40. ing.1 95.59). there was also a significant improvement in using images.7 Melanoma 37.6% for dermoscopy.3 NA NA NA NA analysis NA—not applicable.0 20.05).3 71.4 85. Similarly. % VALUE. P = .0% for 0. there was a significant improvement in melanoma Lesions N (%) N (%) diagnosis using surface microscopy photographs versus Argenziano et al22 2536 92 (3.1% vs 37.3% to 85. P = . (67. P = .0)  20 (50.9% vs 37. Westerhoff et al23 Table 3.1 84.7 only Dolianitis et al25 Melanoma only • Menzies 60. with no significant differences found in 3 Sensitivity for naked-eye examination (melanoma of the studies.0) Table 2.6) 12 (0.0 84.9 68. Vol 58:  JuLY • JUILLET 2012 | Canadian Family Physician • Le Médecin de famille canadien  743 .8 vs 6.4 73. tion.8% to 89.8 11. P = .6% In addition. Dolianitis et al25 demonstrated higher sensitivity for melanoma detection using any of the 4 Dolianitis et al 25 40  20 (50.4 85. 5.295).4 77.7%.  The main results of all melanoma significantly increased for dermoscopy com- studies are presented in Table 2. Dermoscopy for melanoma detection in family practice | Clinical Review al.4 NA NA NA NA • Pattern 60.5% to identified benign lesions when using dermoscopy and 60.9% compared with 53.1 Westerhoff et al23 Melanoma 54. tion (17% increase.3 93.

336).23 low likelihood that family physicians would choose to How sustainable are dermoscopic skills after train- not refer a patient with a suspicious lesion to a derma. and was participants in the study by Dolianitis et al25 were not only preferred most by participants. This suggests that dermoscopy is a Dermoscopy has been shown to be a useful and fairly useful tool in clinical practice.3 vs 85. there are a number of ways to learn naked-eye examination. the dermoscopy training between the dermoscopy group (98.209) and for melanoma (92. Of note. dermoscopy was found to be dermoscopy techniques—through self-teaching with an between 12% and 98% better at identifying a skin lesion introductory or comprehensive dermoscopy textbook.5:1.6%). This was similar to 2 of family physicians but also included dermatologists and the other papers discussed.004). in the study by Research has shown that dermatologists perform better Dolianitis et al25 only the specificity for pattern analy. Unlike the other 3 studies. using pattern analysis. checklist. when taking into account only the pat.24. 6. dermoscopy has higher by naked-eye examination but only 6 were missed using sensitivity for melanoma detection than naked-eye exam- dermoscopy (P = . 744  Canadian Family Physician • Le Médecin de famille canadien | Vol 58:  JuLY • JUILLET 2012 . Menzies et al24 reported that there use of dermoscopy will very likely outweigh all of these was a significant improvement in the benign pigmented drawbacks.27 or as malignant. However.97). ination with generally no decrease in specificity.1%) and sensitivity (84. anoma in the general population differs from preva. However. What are the potential disadvantages? As previously Positive predictive value and NPV depend on the mentioned.001). As long as examination and dermoscopy for all malignant lesions physicians are using dermoscopy. P = .22 could be another useful choice. Further. which dermoscopy algo- sis was not significantly different from clinical examin.7%. 25 but they could be just another necessary tool in the office.20 However.25 The negative LR calcu.23. Positive LRs were only presented this is relatively inexpensive and could be considered in the paper by Dolianitis et al. Nonetheless.8%) (P = . like an otoscope calculated with the available data in the studies by or fundoscope.4.001). they be significantly higher than the specificity of the other 3 concluded that the Menzies method had the highest diag- dermoscopic algorithms. materials provided. can help to improve physicians’ nificant difference in negative predictive value (NPV) diagnostic skills. Interestingly. a family physician must dedicate time for these calculations. likelihood ratios few hundred dollars for a simple dermatoscope to more (LRs) are a more useful measure. The increase in confidence and the utility of dermoscopy is the effect on unnecessary improvement in diagnostic accuracy that comes with the lesion excision rates. this suggests that there is a of naked-eye clinical examination as well. Therefore. the paper by Dolianitis et al25 suggested that pattern analy- the specificity of naked-eye examination was found to sis had the highest specificity among non-experts.7:1 Conclusion vs 9. with supplemental reference Only the study by Argenziano et al22 reported a sig. lence in the studies. rithm would be best for family physicians to use? Although ation (85. the physician will become more As previously mentioned. as prevalence of mel. P = .24.22. dermoscopy was 20% to 57% better at identifying ine patients with the dermatoscope. than a thousand dollars for the more advanced devices.22. program in 1 paper significantly increased the sensitivity eye group (95. P = .002).24 The paper by Another foreseeable drawback is that in order to learn Westerhoff et al23 did not provide the necessary data this new skill set.25 any other new skill.24 Perhaps the new 3-point dermatology trainees who were not dermoscopy users. this will help to keep (91.24 there was a months and successfully demonstrated that dermoscopy non-significant improvement in NPV between naked-eye was effective at least this long after training. Argenziano et al. In the study by Menzies et al. depending on the manufacturer and model. 94.3. dermoscopy course. titioners are better trained at detecting nonmelanomas The reviewed studies indicate that even a 1-day with the naked eye. Family medicine residents could be taught during Negative LRs were calculated from the available data an academic day or in procedure clinics. there is a cost for the device.25 shop. For positive LRs.1%) and the naked. like a skin lesion as benign (Table 4).3 vs 7. However.7%. P < . P = . An additional concern for some physicians might lation revealed that compared with naked-eye examin.27 Argenziano et al22 and Menzies et al. perhaps through a continuing medical education work- tern analysis algorithm in the paper by Dolianitis et al. lesion–to-melanoma ratio of excised or referred lesions using dermoscopy versus naked-eye examination (3. be that at first they would require more time to exam- ation. It is possible that because the nostic accuracy (81. Among family physicians. ing? The study by Argenziano et al22 continued for 16 tologist.Clinical Review | Dermoscopy for melanoma detection in family practice dermoscopy compared with naked-eye examination (16% Discussion increase.7% vs up their skills. which was shown to be effective in the paper by the results might be skewed in that these medical prac. compared with to training. presented in the 3 studies. Argenziano et inexpensive tool for melanoma detection in family prac- al22 found that 23 malignant tumours were not identified tice. an important measure of proficient with time.3% vs 93. ranging from a prevalence of a disease.

74 0.  Epiluminescence microscopy. Ont. Sammarco E. Nardini P. Pontén F. Yadav S. Silverman M. e-mail drherschorn@gmail.29 55 Menzies et al24 All malignant 2. 26. Br J Dermatol might even help to increase family doctors’ ability to 2004. Toronto. The training Improvement of malignant/benign ratio in excised melanocytic lesions in the ‘dermoscopy era’: a retrospective study 1997-2001. Chiarugi A. ON: Cancer Care Ontario. assessed as being malignant is in fact malignant and that 11. Winkler A. 2008. Johnston M. Macaskill P. 17. life care.147(3):481-6. Secchi T. Comparative performance of 4 7. suggestive of skin cancer. Stiener A.86(10):761-9. McCarthy WH. Fletcher J. Dermatol Clin 2001. Fox GN.83 98 0. Davies S. Salopek TG. et al.00 - 29 0.44(6):979-86. Adami HO. de Giorgi V. ON: Public Health Agency of Canada. Canadian Cancer Statistics 2010: special topic end of the Internet. Chiarugi A. Talamini R. Verhaeghe E. Crocetti E. Scope A. Thörn M. Kaider A. Bleyen L. assist in decreasing unnecessary biopsies. Grob JJ. Vol 58:  JuLY • JUILLET 2012 | Canadian Family Physician • Le Médecin de famille canadien  745 . Available from: 21.19(1):32-9. technique can increase family physicians’ confidence Addition of dermoscopy to conventional naked-eye examination in melan- oma screening: a randomized study. in their referral accuracy to dermatologists. Corona R. Bleyen L. Carli P. Stefanato C. Sparén P. Pattern analysis of pigmented skin lesions. Corona R. Toronto. Diadone R. Sydney. 1996. Arch Dermatol 1995. Arch Dermatol 2006. Vestergaard ME. Dermoscopy of pigmented skin lesions: results of a consensus meeting via 2.20 57 • 7-point checklist 3. Arch Dermatol 2005.com 19. Salaudek I. The “ugly duckling” sign: agreement between observers.ca. Bak K. Canadian Cancer Society.00 - 5 0. Australia: McGraw-Hill International al. Rabinovitz H.71 0. Dermoscopy for melanoma detection in family practice | Clinical Review Table 4.60(5):301-16.70 12 0. 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