10.5826/dpc.1303a212
Introduction: Malignant melanoma (MM) is one of the most fatal skin cancers. Early detection and treatment are crucial for metastasis prevention. The growing number of MM cases has led to an increased need for skin examinations, increasing the healthcare demand in dermatology departments.
Objectives: The purpose of this cross-sectional, retrospective study was to analyze the accuracy and reliability of two different methods, teledermoscopy (TD) and face-to-face examination (FTF), with two different patient groups for MM detection in Jönköping County.
Methods: In teledermoscopic evaluation, a general practitioner takes photographs of a suspected skin lesion (clinical and dermoscopic images) and sends TD referrals to a dermatologist for digital assessment. In the FTF group, the diagnosis was made during regular clinical visits to the dermatology department by a dermatologist.
Results: The TD group comprised 55 women and 57 men, and an FTF group comprised 72 women and 66 men. Based on the histopathology report, in the TD group, 75% of suspected MM lesions were accurately classified as MM compared with 57% of suspected MM lesions correctly diagnosed in the FTF group. When compared with histopathology report, the diagnostic concordance of TD and FTF examinations were 80% and 69%, respectively.
Conclusions: We report a high diagnostic concordance between TD and the final histopathological diagnosis. Metrics analyzed for diagnostic accuracy confirmed that TD is an effective and accurate method for early diagnosis of MM. TD is suitable, non-inferior and a useful alternative to FTF examination.
text/xml
2160-9381
3217
en
Oliver Seifert
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
telemedicine
Analysis of Teledermoscopy and Face-to-Face Examination of Atypical Pigmented Lesions: a Cross-Sectional, Retrospective Study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2023-02-04
2023-07-31
2023-08-24
e2023212
Dermatol Pract Concept
Introduction: Malignant melanoma (MM) is one of the most fatal skin cancers. Early detection and treatment are crucial for metastasis prevention. The growing number of MM cases has led to an increased need for skin examinations, increasing the healthcare demand in dermatology departments.
Objectives: The purpose of this cross-sectional, retrospective study was to analyze the accuracy and reliability of two different methods, teledermoscopy (TD) and face-to-face examination (FTF), with two different patient groups for MM detection in Jönköping County.
Methods: In teledermoscopic evaluation, a general practitioner takes photographs of a suspected skin lesion (clinical and dermoscopic images) and sends TD referrals to a dermatologist for digital assessment. In the FTF group, the diagnosis was made during regular clinical visits to the dermatology department by a dermatologist.
Results: The TD group comprised 55 women and 57 men, and an FTF group comprised 72 women and 66 men. Based on the histopathology report, in the TD group, 75% of suspected MM lesions were accurately classified as MM compared with 57% of suspected MM lesions correctly diagnosed in the FTF group. When compared with histopathology report, the diagnostic concordance of TD and FTF examinations were 80% and 69%, respectively.
Conclusions: We report a high diagnostic concordance between TD and the final histopathological diagnosis. Metrics analyzed for diagnostic accuracy confirmed that TD is an effective and accurate method for early diagnosis of MM. TD is suitable, non-inferior and a useful alternative to FTF examination.
Oliver Seifert
2023/07/31
10.5826/dpc.1303a212
e2023212
Department of Dermatology and Venereology, Ryhov County Hospital, Jönköping; Division of Cell Biology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
2160-9381
telemedicine
en
e2023212
Vestergaard T, Prasad SC, Schuster A, Laurinaviciene R, Andersen MK, Bygum A. Diagnostic accuracy and interobserver concordance: teledermoscopy of 600 suspicious skin lesions in Southern Denmark. J Eur Acad Dermatol Venereol. 2020;34(7):1601-1608. DOI:10.1111/jdv.16275. PMID: 32031277.
Analysis of Teledermoscopy and Face-to-Face Examination of Atypical Pigmented Lesions: a Cross-Sectional, Retrospective Study
https://dpcj.org/index.php/dpc/article/download/3217/2117
         Analysis of Teledermoscopy and Face-to-Face
         Examination of Atypical Pigmented Lesions:
           a Cross-Sectional, Retrospective Study
                          Nor Fazil Jaber1, Sandra Jerkovic Gulin1,2, Oliver Seifert1,2


1 Department of Dermatology and Venereology, Ryhov County Hospital, Jönköping, Sweden
2 Division of Cell Biology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden



Key words: dermoscopy, dysplastic nevi, melanoma, telemedicine
Citation: Fazil Jaber N, Jerkovic Gulin S, Seifert O. Analysis of Teledermoscopy and Face-to-Face Examination of Atypical Pigmented
Lesions: A Cross-Sectional, Retrospective Study. Dermatol Pract Concept. 2023;13(3):e2023212. DOI: https://doi.org/10.5826
/dpc.1303a212
Accepted: March 30, 2023; Published: July 2023
Copyright: ©2023 Fazil Jaber et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: Futurum - The Academy for Healthcare, Region Jönköping County
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Sandra Jerkovic Gulin, Dermatology and Venereology Specialist, Division of Dermatology, Ryhov Hospital,
Jönköping; Department of Biomedical and Clinical Sciences Division of Cell Biology Faculty of Medicine and Health Sciences Linköping
University, SE-581 83 Linköping, Sweden. Tel: +46 (0)730362719 Email: sandra.jerkovic.gulin@liu.se




  ABSTRACT             Introduction: Malignant melanoma (MM) is one of the most fatal skin cancers. Early detection and
                       treatment are crucial for metastasis prevention. The growing number of MM cases has led to an in-
                       creased need for skin examinations, increasing the healthcare demand in dermatology departments.
                       Objectives: The purpose of this cross-sectional, retrospective study was to analyze the accuracy and
                       reliability of two different methods, teledermoscopy (TD) and face-to-face examination (FTF), with
                       two different patient groups for MM detection in Jönköping County.
                       Methods: In teledermoscopic evaluation, a general practitioner takes photographs of a suspected
                       skin lesion (clinical and dermoscopic images) and sends TD referrals to a dermatologist for digital
                       assessment. In the FTF group, the diagnosis was made during regular clinical visits to the dermatology
                       department by a dermatologist.
                       Results: The TD group comprised 55 women and 57 men, and an FTF group comprised 72 women
                       and 66 men. Based on the histopathology report, in the TD group, 75% of suspected MM lesions were
                       accurately classified as MM compared with 57% of suspected MM lesions correctly diagnosed in the
                       FTF group. When compared with histopathology report, the diagnostic concordance of TD and FTF
                       examinations were 80% and 69%, respectively.




Original Article | Dermatol Pract Concept. 2023;13(3):e2023212                                                                         1
                      Conclusions: We report a high diagnostic concordance between TD and the final histopathological
                      diagnosis. Metrics analyzed for diagnostic accuracy confirmed that TD is an effective and accurate
                      method for early diagnosis of MM. TD is suitable, non-inferior and a useful alternative to FTF exam-
                      ination.




Introduction                                                        Sweden. Clinical data, histopathological results, age, sex,
                                                                    heredity, and history of skin cancer were obtained from the
Malignant melanoma (MM) is one of the most serious and fa-          electronic patient journal system CAMBIO Cosmic (Swed-
tal skin cancers that has steadily increased worldwide over the     ish health care information system, version 8.0). The Inter-
recent decades [1]. When a skin lesion is clinically suspected to   national Statistical Classification of Diseases, 10th revision
be MM, it is examined with a dermatoscope [2]. If dermoscopic       (ICD-10), code D229F was used to identify all patients with
examination strengthens the suspicion of melanoma, the entire       clinically suspect AML and MM in Cosmic. The assessment
lesion is excised and sent to the laboratory for histopathologi-    of pigmented lesions via FotoFinder (Systems GmbH) is not
cal examination under acute procedure (standardised care pro-       included in this study because the patients who are regularly
cess [SCP]) [3]. The term atypical melanocytic lesion (AML)         followed by FotoFinder may carry CDKN2A mutations,
should be used when clinical evaluation fails to fully determine    which may bias the study results. Otherwise, all patients
whether the skin lesion is melanoma or a benign pigmented           were included in this study without any restrictions.
lesion. In teledermoscopic (TD) evaluation, a general practi-          In the present study, patients were divided into two
tioner takes photographs of a suspected skin lesion and sends       groups according to their assessment mode: FTF and TD.
TD referral to the dermatology department. The first regions        The clinical images in the TD group were obtained by dif-
to introduce TD in Sweden were Council County Västerbot-            ferent general practitioners using a standardized, uniform
ten and Gävleborg in 2014. Since then, many regions have in-        system for our county (using digital camera Canon Ixus 185
troduced TD. Some studies compared the reliability between          for pictures from a distance and a dermoscopic photo using
teledermoscopic and face-to-face (FTF) examinations, with           Heine delta 20 SLR photoadaptor attached to Canon cam-
diagnostic reliability ranging from 81% to 91% full or partial      era) in polarized mode without using flash. The pictures for
diagnostic concordance [4]. Other studies showed similar pre-       the TD assessment were uploaded by a general practitioner
cision between TD and FTF examinations and some studies             to the Cosmic electronic journal system and then analyzed
found that TD was significantly superior to FTF examination         by one of totally thirteen different dermatologists (mostly
while other studies showed that the diagnostic accuracy of          senior). All low-quality images were excluded from the be-
TD was inferior to FTF examination. [5-9]. Data on the accu-        ginning and sent back to the referral doctor to retake and
racy and reliability of TD in Sweden are scarce. There are no       resend higher-quality pictures for new examination.
major scientific studies on the proportion of AML surgically           The diagnosis was made based on a patient history and
removed via TD referrals compared with FTF in Jönköping             clinical and dermoscopic image (TD) evaluation. In the FTF
County, Sweden. The growing number of MM cases has led to           group, the diagnosis was made during regular clinical visits
an increased need for skin lesion examination, increasing the       to the dermatology department by one of same dermatolo-
healthcare demand in dermatology departments [10].                  gists as in TD group.
                                                                       Pigmented lesions in the TD and FTF groups were subdi-
Objectives                                                          vided into two groups: clinically suspected MM and AML.
                                                                    Histopathological results were obtained for all patients.
The aim of our cross-sectional, retrospective study was to as-      Each subdivision was further divided depending on the his-
sess the diagnostic reliability of TD and FTF examinations. It      topathological diagnosis of benign nevus, mild, moderate,
is important to note that the reliability measurements reported     severe dysplastic naevi and MM (malignant melanoma in-
in this study are specific to the TD service being evaluated.       cluding melanoma in situ). The results for clinically suspected
                                                                    MM in these two groups were compared for reliability. The
Methods                                                             histopathological results for MM and severe dysplastic nae-
                                                                    vus were both classified as MM and are summarized in a
This cross-sectional, retrospective study was performed             MM group and this due to the fact that at our department,
between 1 January and 30 June 2020 at the Department                we adhere to the national guidelines for the surgical removal
of Dermatology, Ryhov County Hospital in Jönköping,                 of dysplastic nevi and melanoma in situ. For cases of severe



2                                                                       Original Article | Dermatol Pract Concept. 2023;13(3):e2023212
dysplastic nevus and melanoma in situ, primary excision                      Results
with a 5mm margin is recommended. Re-excision is required
only if the histopathological free margin is less than 2mm.                  Study Population
However, for cases of low-grade dysplastic nevus, primary                    The TD group comprised 55 women and 57 men, and the
excision with a histopathological-free margin, even if it is                 FTF group comprised 72 women and 66 men. The number
less than 2mm, does not necessitate re-excision. Distinguish-                of patients and sex distribution in both groups were nearly
ing between severe dysplastic nevi and melanoma in situ can                  similar. In the FTF group, the median age of patients at the
be challenging. Moderately-to-severely and severely dysplas-                 time of diagnosis was higher than in the TD group. The rate
tic nevi are more frequently associated with melanoma com-                   of family history of non-melanoma skin cancer (NMSC) was
pared to mildly or moderately dysplastic nevi.                               higher in the FTF group than in the TD group, and the rate of
    Results for mild and moderate dysplastic naevi and be-                   family history of MM was approximately five times higher
nign lesions were included in a benign lesion group (Figure 1).              in the FTF group than in the TD group. Even the rate of per-
                                                                             sonal history of skin cancer, including NMSC and MM, was
Statistical Analysis                                                         higher in the FTF group (Table 1).
Quantitative and demographic data were presented using
descriptive statistics. Chi-square and Fisher exact tests were               No Significant Differences in MM Detection
used to compare the number of benign and malignant cases                     between the TD and FTF Groups
in the FTF and TD groups. Statistical significance was set                   Of the 101 cases in the TD group, 61 cases were included
at P < 0.05. Diagnostic accuracy describes the ability of a                  in the suspected AML group and 40 cases in the suspected
diagnostic test to distinguish between disease and health.                   MM group. Of the 134 cases in the FTF group, 96 cases
To measure and compare the diagnostic accuracy of the TD                     were included in the suspected AML group, and 38 cases in
and FTF examinations, the metrics sensitivity, specificity,                  the suspected MM group. Based on histopathology reports,
and positive and negative predictive values (PPV and NPV,                    75% cases in the suspected MM group of the TD group were
respectively) were calculated and presented as percentages.                  classified accurately as MM compared with 57% in the sus-
A receiver operating characteristic (ROC) curve was con-                     pected MM group of the FTF group. No statistically signif-
structed, and the area under the curve (AUC) was calculated                  icant difference was observed in the frequency of correctly
[11-13]. Furthermore, diagnostic effectiveness, expressed as                 diagnosed MM between the TD and FTF groups (Chi-square
the proportion of correctly classified subjects among all sub-               test, P = 0.109; Fisher test, P = 0.15), suggesting that TD and
jects was analyzed.                                                          FTF examinations are equivalent in detecting MM. The total



                                   TD                                                                         FTF




                               n = 112                                                                     n = 138
                           pigmented lesions                                                           pigmented lesions
                               (D229F)                                                                     (D229F)




   n = 31                                      n = 11                                                                      n=4
                        n = 101                                                    n = 51          n = 134
   benign                                       data                                                                       data
                        excised                                                    benign          excised
                                               missing                                                                    missing




       n = 13
       MM in                              n = 39                                       n = 19
                        n = 18          dysplastic                                     MM in                          n = 53
        situ                                                                                        n = 11
                         MM                                                             situ                        dysplastic
                                                                                                     MM



                                  n = 29                      n = 10                                                                 n = 16
                                                         severe dysplastic                                   n = 37
                             mild & moderate                                                                                         severe
                                                               nevi                                     mild & moderate
                             dysplastic nevi                                                                                     dysplastic nevi
                                                                                                        dysplastic nevi


Figure 1. Flow Chart.
TD = teledermoscopy; FTF = face-to-face; MM = malignant melanoma.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023212                                                                                     3
        Table 1. Demographic data for all patients with pigmented lesions included in this study.
                                                                                                        TD                 FTF
 Sex                                                               male, N (%)                      57 (50.9)          66 (47.8)
                                                                   female, N (%)                    55 (49.1)          72 (52.2)
 Age                                                               median (min–max)                55 (18–91)         68 (43–92)
 Age depending on histopathological diagnosis                      benign                           45 (18-86)         56(10-92)
                                                                   mild and moderate                50 (19-86)         53 (27-88)
                                                                   dysplastic
                                                                   severe dysplastic                63 (45-68)         48 (29-81)
                                                                   MM                              64 (36–91)          75 (58-82)
 Family history of skin cancer                                     NMSC, N (%)                        3 (2.9)            6 (4.4)
                                                                   MM, N (%)                          1 (1.0)          26 (19.1)
 Personal history of skin cancer                                   NMSC, N (%)                        2 (1.8)          24 (21.4)
                                                                   MM, N (%)                        13 (11.6)          31 (27.7)

AUC = area under curve; FTF = face-to-face; NPV = negative predictive value; PPV = positive predictive value; ROC = receiver operating
characteristic analysis; TD = teledermoscopy.




number of patients with suspected MM was similar in the
                                                                     Conclusions
TD and FTF groups (Figure 2).
    The number of lesions classified as AML was almost               Our study results are consistent with those of other studies
40% higher in the FTF group than in the TD group. The                [14-17]. We report a high (80%) diagnostic accuracy be-
proportion of clinically misdiagnosed AML, in which his-             tween TD and the final histopathologic diagnosis, similar to
topathology showed MM or severe dysplastic naevi, was                some previous studies.
higher in the FTF group (25%) than in the TD group                       Compared to other TD studies that have shown compa-
(18%). However, no statistically significant difference was          rable diagnostic accuracy between TD and FTF examina-
observed in the frequency of misdiagnosed MM between                 tions [4,5,18], the diagnostic accuracy of FTF in our study
the groups (Chi-square test, P = 1.19; Fisher test, P = 0.235),      was slightly lower (69%) than TD (80%), which may be due
suggesting that TD and FTF examinations are comparable               to the different study designs. In our study, the TD and FTF
for detecting MM. In addition, the diagnosis of MM and               groups included different patients. Most patients in the FTF
benign naevus was twice as high in the FTF group as in               group were older and high-risk patients with a higher rate
the TD group; nevertheless, the number of cases of mild,             of personal and family history of skin cancer, making the
moderate, and severe dysplastic naevi was nearly similar             group-comparison difficult. It is possible that the higher inci-
(Figure 2).                                                          dence of missed melanomas in FTF group occurs in patients
                                                                     with extensive sun damage or atypical nevus syndrome could
TD and FTF are Comparative in Detecting MM                           be related to the comprehensive full-body exams conducted
To investigate the reliability of TD and FTF examinations in         during these checks, as opposed to TD referrals that typically
differentiating malignant from benign lesions, the sensitivity,      focus on one to three specific lesions. Some studies have re-
specificity, predictive value, and diagnostic effectiveness were     ported false-negative diagnoses in the management of high-
calculated. Compared with the histopathological diagnosis,           risk patients [19].
the diagnostic effectiveness of TD was 80% with a sensitiv-              In contrast to our study, other studies have shown the
ity of 75%, specificity 83.9%, PPV 75% and NPV 83.6%,                inferiority of TD in terms of accuracy compared to FTF ex-
and for the FTF examination, it was 69% with a sensitivity           amination [20]. Börve et al reported 66.7% accuracy for
of 47.8%, specificity 81.2%, PPV 57.9%, and NPV 74.7%                FTF examination which is similar to our study. However, the
(Table 2).                                                           same study has shown a diagnostic accuracy of 50.7% and
    In this study, TD evaluation of pigmented lesions showed         60.9% for TD by teledermoscopists 1 and 2, respectively,
slightly higher scores for sensitivity and accuracy but nearly       which is lower than that of our study. Notably, the number of
similar specificity compared to FTF diagnosis.                       cases (69) in this study was smaller, and the study period (16
    The AUC for TD was 0.79, indicating good accuracy,               weeks) was shorter than in our study [20]. Moreover, both
whereas the FTF evaluation of pigmented lesions showed               examinations were performed by the same dermatologist,
sufficient accuracy (AUC=0.64).                                      which was not the case in our retrospective study. Although



4                                                                        Original Article | Dermatol Pract Concept. 2023;13(3):e2023212
 Figure 2. Number of benign or malignant lesions assessed by TD and FTF examinations for melanoma and atypical melanocytic lesion
 diagnosis.
 TD = teledermoscopy; FTF = face-to-face; MM = malignant melanoma; SCP = standardized care process; AML = atypical melano-
 cytic lesion.




 Table 2. Diagnostic accuracy and reliability of                   excluding low-quality images, resulting in a higher sensitivity
 TD and FTF examinations for all patients with                     of TD than would have been found in a general population.
  suspicious MM (malignant melanoma under                          TD relies heavily dependent on high-quality images [21,22].
           standardized care process).                             The cases included in our study consisted of only good qual-

                                           TD            FTF       ity images, as all low-quality images were excluded from the
                                                                   beginning and sent back to the referral doctor to retake and
 Sensitivity (%)                           75            47.8
                                                                   resend higher-quality pictures for new examination.
 Specificity (%)                          83.9           81.6
                                                                      Interestingly, another study reported similar results, with
 PPV (%)                                   75            57.9
                                                                   TD showing lower accuracy and reliability than FTF ex-
 NPV (%)                                  83.6           74.7
                                                                   amination in general practice. However, image quality was
 AUC (n)                                 0.793          0.647
                                                                   rated as good in only one-third of cases, and the diagnostic
 Diagnostic effectiveness                0.802          0.699      and accuracy rates were higher, particularly in cases with
FTF = face-to-face; MM = malignant melanoma; NMSC =                good quality photographs [21].
­non-melanoma skin cancer; TD = teledermoscopy.                       A systematic review of 21 studies [23] showed that
                                                                   teledermoscopist-histology accuracy was 51–85%, and in
                                                                   cases of FTF examination, the accuracy was higher (67%–
TD was analyzed by different dermatologists in our study,          85%). Most studies in this review had remarkable method-
TD accuracy was slightly higher. The higher accuracy for TD        ological limitations in terms of diagnostic accuracy. Another
reported in our study can be due to the smaller study size         study found significant differences in diagnostic accuracy
compared to Börve et al. Additionally, that study had a se-        between TD and FTF examinations when different derma-
lection bias because only lesions requiring biopsy or excision     tologists evaluated lesions; this difference could be due to
were included. The teledermoscopists were aware of this fact,      different definitions of the terms. [24] As in our study, it is
which may have influenced their management decisions. In           very difficult to say whether the limited agreement in diag-
addition, the teledermoscopists rated 14 different cases out       noses is related to the use of the technology itself or differ-
of 69 as having poor image quality. In our study, we reduced       ences in dermoscopy skills that may exist in practice. Tan
the risk of selection bias by enrolling high-risk patients and     et al reported higher diagnostic accuracy when the same



Original Article | Dermatol Pract Concept. 2023;13(3):e2023212                                                                      5
dermatologist performed both methods (κ = 0.95; range,             research, we suggest that the same patient group be included
0.91–0.99) [24].                                                   in both TD and FTF assessments as the comparison of the two
    A recent large prospective study conducted in Denmark          methods will be accurate with a valid gold-standard method
showed no significant difference in sensitivity between FTF        available. Another limitation of this study was the small sam-
and TD; however, the specificity for TD was lower than for         ple size. We suggest that TD is an effective and accurate method
FTF examination. [25] The data are inconsistent with our           for early diagnosis of MM, it is suitable and non-inferior to
study, which showed no significant difference in specificity       FTF examination in detecting MM. TD reduces healthcare
(83% versus. 81%) between the two methods and a lower              costs and is a useful alternative to FTF examination. TD has
sensitivity for FTF examination than TD (47.8% versus              been shown to exhibit high reliability, resulting in a decrease
75%). This could be due to the retrospective nature of our         in the number of unnecessary referrals and waiting time, not
study with different patients with higher risk factors in FTF      only for patients residing in remote rural areas but also for
group which influences the comparison of sensitivity of the        those facing challenges in accessing specialist care. Education
two groups.                                                        in the field of dermoscopy and TD implementation in the ev-
    We believe that the higher diagnostic accuracy and sen-        eryday life of dermatologists may improve fast and accurate
sitivity of TD in our study compared with lower diagnostic         melanoma diagnosis in a larger number of patients, which
accuracy and sensitivity of FTF examination is due to several      may lead to earlier melanoma diagnosis and reduce morbidity
different factors. The evaluation of clinical and dermoscopic      and treatment costs. Larger studies are needed to confirm the
images by TD in a quiet environment and with a wide screen         results of the present study. Continued studies with a reduced
resolution that focuses more on a specific lesion can improve      risk of bias in assessing diagnostic accuracy and education in
the diagnosis of benign and malignant skin tumors. The pa-         this field with advanced photography techniques will proba-
tients included in the FTF group had a higher median age and       bly improve the quality of TD assessment care.
more family and personal history of skin cancer compared
with patients in the TD group, complicating the diagnosis
in the FTF group with several risk factors. Namely, there is       References
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Original Article | Dermatol Pract Concept. 2023;13(3):e2023212                                                                                7
