Dermatoscopy in General Practice

A review by Professor David Wilkinson of two articles that focus on dermatoscopy in general practice.

A note from Professor David Wilkinson:

“The purpose of my monthly research blog posts is to share interesting, recent material from the world’s leading journals. And, importantly, to provide useful updates on aspects of clinical practice. This month, I share two recent pieces for your review and consideration.

The first is a short commentary from Associate Professor Cliff Rosendahl, who is known to many of us and is a skin cancer GP in Queensland. I had the pleasure of supporting Cliff through his PhD when I was Dean of Medicine at UQ. In this piece, Cliff provides commentary on a paper that looked at use of, and interest in, dermatoscopy among GPs in France. The commentary from Cliff is below – he argues for improved teaching of dermatoscopy among medical students in Australian medical schools. What do you think?

The second short paper is fascinating, and speaks to a question I am asked a lot. Do patients care about the gender of the doctor doing their skin check? Remarkably there is very little research on this topic. Again, this short research report is below for your interest. This is a short report and is well worth a read! Fascinating findings – will any of this change your practice?”

Research article 1: Dermatoscopy in General Practice

‘Melanoma writes its message on the skin with its own ink and it is there for all to see. Unfortunately some see but do not comprehend.’ Since Neville Davis made this statement in the Annals of Plastic Surgery in 1978, the advent of dermatoscopy has facilitated earlier diagnosis of melanoma, as well as enhancing diagnostic accuracy for many dermatological conditions, both benign and malignant. Such is the level of evidence for the diagnosis of melanoma that dermatoscopy is now the standard of care in Australasia for clinicians treating pigmented skin lesions. With skin conditions accounting for up to 14.8% of all consultations in general practice it has been suggested that dermatoscopy is now as applicable in that discipline as is use of the stethoscope.

In their study in this edition of the BJD, Chappuis et al. deliver detailed findings of the first assessment of dermatoscopy use by French general practitioners (GPs), reporting that 8% of respondents possessed a dermatoscope and 16.9% had received training in dermatoscopy.

This low level of usage of dermatoscopy is not unique to GPs or to France. Studies on dermatoscopy use, cited in the study by Chappuis et al., suggest that while use appears to be high by dermatologists in Europe and Australia (94.6% in France and 98% in Australia), less than half of the dermatologists surveyed in a cross-sectional survey in the U.S.A. in 2010 had used a dermatoscope, although a more recent survey suggests use may have increased to around 79%. The only other study that attempted to quantify dermatoscopy use by GPs reported that one-third of respondents, in Australia in 2007, used dermatoscopy.

In the twenty-first century, debate about the merits of dermatoscopy is as inappropriate as debate about the merits of using an otoscope. Cited drawbacks such as cost and time constraints are no longer tenable and any perceived lack of efficacy of dermatoscopy is likely to be related to lack of training and experience rather than to science.

It is time for a paradigm shift in attitude and practice and such changes start not at workshops for graduate doctors, no matter how appropriate these are, but in medical school. The kit of stethoscope, patella hammer, ophthalmoscope and otoscope, which adorned the twentieth-century medical student’s white coat, should have the dermatoscope added to it. Instruction in the use of this relatively low-cost hand-held device should be an integral part of teaching in medical school as well as in advanced training programmes for GPs.

The study by Chappuis et al. found that GPs in France were receptive to training in dermatoscopy. The time is ripe to respond to this, not only for GPs in France, but for medical students globally. This will bring us one step closer to the dream of the late Bernie Ackerman: that no person should die of melanoma.

Click here to download the full paper  

Research article 2: Patient Preferences During Skin Cancer Screening Examination

The results are very interesting and you might also want to read to understand the patients psychology of choosing the gender of the doctor for their skin check. 

patient-preference-1  patient-preference-2

Click here to download the full paper 

Learn more about skin cancer medicine in primary care at the next Skin Cancer Certificate Courses:

Skin Cancer Certificate Courses in Australia

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One comment on “Dermatoscopy in General Practice

  1. I agree with Prof Wilkinson that Dermatoscopy should be taught to all medical graduates & should be part of GP curriculum
    Below is a published study in BJD of a trial that I did with Prof Scott Menzies in Perth WA with GPs

    British Journal of Dermatology

    View issue TOC
    Volume 161, Issue 6
    December 2009
    Pages 1270–1277
    Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: a sequential intervention trial
    Background  Studies have shown the benign to malignant ratio of excised pigmented skin lesions is suboptimal in primary care.
    Objectives  To assess the impact of dermoscopy and short-term sequential digital dermoscopy imaging (SDDI) on the management of suspicious pigmented skin lesions by primary care physicians.
    Methods  A total of 63 primary care physicians were trained in the use of dermoscopy and SDDI (interventions) and then recruited pigmented lesions requiring biopsy or referral in routine care by naked eye examination. They were then given a dermatoscope and the option of a SDDI instrument, and change of diagnosis and management was assessed.
    Results  Following the use of the interventions on 374 lesions a total of 163 lesions (43·6%) were excised or referred, representing a reduction of 56·4%. Of the 323 lesions confirmed to be benign, 118 (36·5%) were excised or referred, leading to a reduction of 63·5% (P < 0·0005) in those requiring excision or referral. The baseline naked eye examination benign to melanoma ratio was 9·5 : 1 which decreased to 3·5 : 1 after the diagnostic interventions (P < 0·0005). Of the 42 malignant lesions included in the study (34 melanoma, six pigmented basal cell carcinoma and two Bowen disease) only one in situ melanoma was incorrectly managed (patient to return if changes occur) resulting in the correct management of 97·6% and 97·1% of malignant pigmented lesions and melanoma, respectively.
    Conclusions  In a primary care setting the combination of dermoscopy and short-term SDDI reduces the excision or referral of benign pigmented lesions by more than half while nearly doubling the sensitivity for the diagnosis of melanoma.