10.5826/dpc.1203a129
Background: Improving remote triage is crucial given expansions in teledermatology and with limited in-person care during COVID-19. In addition to clinical pictures, dermoscopic images may provide utility for triage.
&nbsp;
Objective: To determine if dermoscopic photographs enhance confidence, triage accuracy, and triage prioritization for teledermatology.
&nbsp;
Methods: In this parallel convergent mixed-methods study, a cohort of dermatologists and residents assessed skin lesions using clinical and dermoscopic photographs. For each case, participants viewed a clinical photograph and determined diagnostic category, management, urgency, and decision-making confidence. They subsequently viewed the associated dermoscopy and answered the same questions. A moderated focus group discussion followed to explore perceptions on the role of dermoscopy in teledermatology.
&nbsp;
Results: Dermoscopy improved recognition of malignancies by 23% and significantly reduced triage urgency measures for non-malignant lesions. Participants endorsed specific utilities of teledermoscopy, such as for pigmented lesions, with limitations including poor image quality.
&nbsp;
Conclusions: Dermoscopic photographs may be useful when remotely triaging skin lesions. Standardized imaging protocols are needed.
text/xml
2160-9381
1880
en
Suephy Chen
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
skin cancer
Dermoscopic Photographs Impact Confidence and Management of Remotely Triaged Skin Lesions
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-07-28
2021-07-29
2022-07-28
2022-09-13
e2022129
Dermatol Pract Concept
Background: Improving remote triage is crucial given expansions in teledermatology and with limited in-person care during COVID-19. In addition to clinical pictures, dermoscopic images may provide utility for triage.
&nbsp;
Objective: To determine if dermoscopic photographs enhance confidence, triage accuracy, and triage prioritization for teledermatology.
&nbsp;
Methods: In this parallel convergent mixed-methods study, a cohort of dermatologists and residents assessed skin lesions using clinical and dermoscopic photographs. For each case, participants viewed a clinical photograph and determined diagnostic category, management, urgency, and decision-making confidence. They subsequently viewed the associated dermoscopy and answered the same questions. A moderated focus group discussion followed to explore perceptions on the role of dermoscopy in teledermatology.
&nbsp;
Results: Dermoscopy improved recognition of malignancies by 23% and significantly reduced triage urgency measures for non-malignant lesions. Participants endorsed specific utilities of teledermoscopy, such as for pigmented lesions, with limitations including poor image quality.
&nbsp;
Conclusions: Dermoscopic photographs may be useful when remotely triaging skin lesions. Standardized imaging protocols are needed.
Suephy Chen
2022/07/28
10.5826/dpc.1203a129
e2022129
Regional Telehealth Service, VISN 7; Department of Dermatology, Duke University
2160-9381
skin cancer
en
e2022129
Dermoscopic Photographs Impact Confidence and Management of Remotely Triaged Skin Lesions
https://dpcj.org/index.php/dpc/article/download/1880/1696
                    Dermatology Practical & Conceptual


       Dermoscopic Images Impact Confidence and
      Management of Remotely Triaged Skin Lesions:
                  a Preliminary Study
           Tova Rogers1*, Myles Randolph McCrary1*, Howa Yeung1,2, Loren Krueger1,
                                      Suephy C Chen2,3#


1 Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA
2 Regional Telehealth Service, VISN 7, Duluth, Georgia, USA
3 Department of Dermatology, Duke University, Durham, North Carolina, USA
*These authors contributed equally to this work.
#
  All work performed while at Emory University, Atlanta, Georgia, USA



Key words: telemedicine, tele-dermatology, dermoscopy, melanoma, skin cancer
Citation: Rogers T, McCrary MR, Yeung H, Krueger L, Chen SC. Dermoscopic images impact confidence and management of remotely
triaged skin lesions: a preliminary study. Dermatol Pract Concept. 2022;12(3):e2022129. DOI: https://doi.org/10.5826/dpc.1203a129
Accepted: December 8, 2021; Published: July 2022
Copyright: ©2022 Rogers 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: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Suephy C. Chen, MD, MS, Department of Dermatology, Duke University School of Medicine, 40 Duke Medicine
Circle, Clinic 3K, Durham, NC 27710, Tel: (919) 684 3110; Fax: (919) 684 3002 E-mail: suephy.chen@duke.edu




  ABSTRACT             Introduction: Improving remote triage is crucial given expansions in tele-dermatology and with
                       limited in-person care during COVID-19. In addition to clinical pictures, dermoscopic images may
                       provide utility for triage.
                       Objectives: To determine if dermoscopic images enhance confidence, triage accuracy, and triage pri-
                       oritization for tele-dermatology.
                       Methods: In this preliminary parallel convergent mixed-methods study, a cohort of dermatologists
                       and residents assessed skin lesions using clinical and dermoscopic images. For each case, participants
                       viewed a clinical image and determined diagnostic category, management, urgency, and decision-
                       making confidence. They subsequently viewed the associated dermoscopy and answered the same
                       questions. A moderated focus group discussion followed to explore perceptions on the role of dermos-
                       copy in tele-dermatology.
                       Results: Dermoscopy improved recognition of malignancies by 23% and significantly reduced triage
                       urgency measures for non-malignant lesions. Participants endorsed specific utilities of tele-dermoscopy,
                       such as for evaluating pigmented lesions, with limitations including poor image quality.
                       Conclusions: Dermoscopic images may be useful when remotely triaging skin lesions. Standardized
                       imaging protocols are needed.




Original Article | Dermatol Pract Concept. 2022;12(3):e2022129                                                                      1
Introduction                                                       every lesion and rash. There is not mandated specific mag-
                                                                   nification or lighting. Images are uploaded via VistA Imag-
Tele-dermatology plays an important role in triage of poten-       ing, an FDA-listed Image Management system employed by
tially malignant skin lesions. Tele-dermatology has compa-         Department of Veterans Affairs healthcare facilities nation-
rable diagnostic accuracy to in-person evaluations, though,        wide. To maintain our imaging quality standards, feedback
study results vary for malignant lesions [1]. The use of der-      for image quality is given for each consult (fully satisfac-
moscopic images, in addition to clinical images, can improve       tory, satisfactory with suggestions, and unsatisfactory). For
accuracy, especially for pigmented skin cancers [2-5].             the present study, images from tele-dermatology consults
    Images are imperative for the remote management of skin        received between 12/1-31/2018 were reviewed. Twenty sets
lesions. Prior to the COVID-19 pandemic, many primary pro-         of clinical and dermoscopic images were selected as represen-
viders would arrange to have patient images taken by trained       tative of common benign and malignant skin lesions seen in
in-office personnel, which are then used for store-and-forward     the tele-dermatology clinic. Diagnoses for malignant lesions
tele-dermatology. There is also an increasing demand for pa-       were confirmed with biopsy. Benign lesions were classified by
tients to submit photographs of their skin problems without        consensus among tele-dermatology providers. Clinical and
needing to go to the primary care office at all. COVID-19          dermoscopic images were de-identified and compiled into a
realized the difficulty of patients to have their skin lesions     digital slide show using Microsoft PowerPoint Version 16.55.
imaged in person. Dermatologists are then faced with using         High image quality was maintained at 300 dots per inch.
patient-provided images taken with smartphones or comput-             This preliminary study was conducted over a two-day
ers [6,7]. The quality of these images is variable. Dermoscopic    period using Zoom, a video communication platform with
images have become almost universally unavailable. While the       a built-in polling function. Participants filled out a demo-
social restrictions resulting from the COVID-19 pandemic are       graphic survey, including a series of questions relating to
loosening, remote patient care has become a possible parallel      their use of dermoscopy in their clinical practices, prior
care paradigm. Thus, to adequately triage patients and main-       dermoscopic training, and overall confidence in their der-
tain high standards of care, innovative means are required to      moscopic abilities. They were shown a clinical image of a
ensure access to high quality images, including assessing the      skin lesion or multiple skin lesions and asked to determine
added value of dermoscopy [1,6,8,9].                               diagnostic category, management decision (reassure versus
                                                                   further in-person management), perceived level of urgency
Objectives                                                         with which further action is required (not urgent, urgent,
                                                                   emergent), and self-rated confidence level in their decision
Our preliminary study aims to assess the impact of dermo-          making (range from 0% to 100% confidence in intervals
scopic images on providers abilities to classify and triage skin   of 10 percentage points) (Supplemental Material, Survey).
lesions, and on their confidence in their decision making. We      Diagnostic categories included non-neoplastic (folliculitis,
implemented a parallel convergent mixed method design to           epidermal inclusion cyst, verruca; 3/20 cases), benign neo-
quantify the utility of dermoscopy for remotely triaging skin      plastic (actinic keratosis, seborrheic keratosis, blue nevus,
lesions and to assess provider’ perceptions of dermoscopy as       sebaceous hyperplasia, dermatofibroma, melanocytic nevus,
a triage tool in tele-dermatology.                                 angioma; 11/20 cases), and malignant neoplastic (mela-
                                                                   noma, basal cell carcinoma, squamous cell carcinoma; 6/20
Methods                                                            cases). These images are supplied in Supplemental Table 1.
                                                                   Participants were then shown the accompanying dermo-
Study Design and Data Collection                                   scopic image and asked the same questions. This process
A convergent parallel mixed-methods design was used to col-        was repeated for all twenty study sets. On study day two,
lect, analyze, and interpret quantitative and qualitative data.    a moderated group discussion took place in which partic-
The study was approved by the Institutional Review Board at        ipants were asked questions pertaining to their perception
Emory University and the Atlanta Veterans Affairs Medical          of the utility of dermoscopic images for triaging skin lesions
Center Research and Development committee. The Veteran             and if the Covid-19 pandemic has changed these perceptions
Integrated Service Network (VISN) 7 TeleDermatology ser-           (Supplemental Material, Debriefing prompts). The discus-
vice serves as a reading hub for the community-based outpa-        sion was recorded and transcribed verbatim.
tient clinics (CBOCs) in Atlanta as well as for other VISN 7
medical centers Imagers are trained by the tele-dermatology        Data Analysis
service to take photographs per standard protocol estab-           GraphPad Prism 6 (GraphPad Software) was used for sta-
lished by the VA National TeleDermatology Service: a forest        tistical analysis and graphic presentation of survey results.
view, and close-up, and a dermoscopic view are taken for           Paired t-tests were used to compare differences in confidence



2                                                                      Original Article | Dermatol Pract Concept. 2022;12(3):e2022129
                 Table 1. Demographics                           practice. Half of survey participants reported using dermos-
                                                                 copy in ≥50% of their clinical practice. Over half (55%)
 Characteristics, N (%)
                                                                 reported having attended at least one formal dermoscopy
 Completed Survey                        22/26 (84.6%)
                                                                 course. When asked about their confidence in their dermo-
 Status
                                                                 scopic abilities, 59% of study participants indicated that
 Resident                                10/26 (38.5%)
                                                                 they were “somewhat confident” using dermoscopy. None of
 Attending                               16/26 (61.5%)
                                                                 the study participants were “confident” in their dermoscopic
 Years in practice (Attendings)                                  abilities.
 1-5                                       4/13 (31%)
 6-10                                      4/13 (31%)            Survey Results
 11-15                                      1/13 (8%)
 > 15                                      4/13 (31%)            Using clinical images alone, 45% of physicians (12/26) cor-
                                                                 rectly diagnosed the study cases. (This increased to 53%
 % Clinical practice using dermoscopy
                                                                 (14/26) after viewing the associated dermoscopic images
 < 50%                                    13/26 (50%)
                                                                 (P = 0.02, paired t-test) (Figure 1). The greatest increase was
 >/= 50%                                  13/26 (50%)
                                                                 for malignant neoplasms (31% [8/26] versus 54% [14/26],
 # Formal dermoscopy courses                                     P = 0.0007).
 0                                       10/22 (45.5%)               After showing clinical images, 54% (14/26) rated
 1-2                                      9/22 (40.9%)           non-neoplastic lesions (ie, inflammatory and infectious) as
 3-4                                      3/22 (13.6%)           “non-urgent”, which significantly increased to 81% (21/26)
 Level of confidence in dermoscopy skills                        after viewing the associated dermoscopic images (P < 0.0001,
 Not confident                            9/22 (40.9%)           McNemar test) (Figure 2). There was a trend to reduce ur-
 Somewhat confident                      13/22 (59.1%)           gency for benign neoplastic lesions (from 69% to 78%
 Confident                                       0               non-urgent) and increase urgency for malignant neoplastic
                                                                 lesions (from 44% to 58% urgent/emergent) following der-
                                                                 moscopic images. With regards to management decisions,
and correct diagnosis before and after revealing dermoscopic     significantly more providers opted to provide reassurance
images. Survey data were expressed as means with 95% con-        (14/26) rather than interventions (0/26) for non-neoplastic
fidence interval. For urgency and management, McNemar’s          lesions following the addition of dermoscopic images
test was used to determine statistical significance in differ-   (P < 0.0001). The addition of dermoscopy did not lead to
ences between the ratings before and after exposure to der-      significant changes in management for benign or malignant
moscopic images. To test whether confidence was correlated       neoplastic lesions.
with correct diagnoses, we used a regression analysis over           We found a 7.6% increase in providers' confidence in
the average self-rated confidence and average percentage         their management decisions with dermoscopy (P < 0.0001)
of correct diagnoses per provider. Results were considered       (Figure 3). There was also a weak but statistically significant
significant if P resulted < 0.05. For qualitative analysis of    (r2 = 0.246 P = 0.024) correlation between providers level
the participant comments, 2 study investigators (TR, MRM)        of confidence and correct diagnoses.
independently reviewed and coded the entire transcript from
the group discussion. Themes were developed inductively          Theme Results
and defined as having at least three study participants having   We conducted a thematic analysis of the moderated discus-
similar responses to the study questions. Investigators con-     sion on the role of dermoscopy for triage during COVID-19
solidated these comments into a list of key themes designed      (Table 2). The first theme involved the specific utilities of
to characterize perceived benefits, potential applications,      dermoscopy. Participants endorsed that dermoscopy was
and shortcomings of dermoscopic images for remotely triag-       useful for suspected malignancy, pigmented lesions, lesions
ing skin lesions. Discrepancies were resolved by consensus.      with well-known dermoscopic features, and in conjunction
                                                                 with patient history, and less useful for generalized exan-
Results                                                          thems. The second theme was image quality. Many voiced
                                                                 that image quality for both clinical and dermoscopic images
Demographics                                                     was critical and often a major limitation. Thirdly, partici-
Twenty-six physicians participated in this preliminary study,    pants commented on accessibility to dermoscopy during the
including 16 dermatology attendings and 10 residents             coronavirus pandemic, and also with technological advances
(Table 1). Attending physicians had a wide spread of years in    and expansions in telehealth. Notably, providers felt that



Original Article | Dermatol Pract Concept. 2022;12(3):e2022129                                                                3
                100                                                                                        100


                 80                                                                                         80




                                                                                          CONFIDENCE (%)
    % CORRECT




                 60                                                                                         60


                 40                                                                                         40


                 20                                                                                         20


                     0                                                                                       0




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                CLINICAL IMAGE
                                                          NE




                                                                                                                                           NE
                DERMOSCOPY                                                                           DERMOSCOPY

Figure 1. Dermoscopy increases % correct diagnoses for malignant                        Figure 3. Dermoscopy increases confidence in management deci-
lesions. The percentage of correct diagnoses for all cases, non-neo-                    sions. The percentage of confidence for all cases, non-neoplastic,
plastic, benign neoplastic, and malignant neoplastic with clinical                      benign neoplastic, and malignant neoplastic with clinical images
images only and following dermoscopic images is shown above. Bar                        only and following dermoscopic images is shown above. Bar graphs
graphs illustrate the means with error bars representing 95% confi-                     illustrate the means with error bars representing 95% confidence
dence intervals. * indicates P < 0.05 at paired t-test.                                 intervals. * indicates P < 0.05 at paired t-test.



                                                                       CLINICAL IMAGE   [1-5,10-13]. Our results indicate that dermoscopy may have
     % RESPONDENTS TRIAGING




                                                                       DERMOSCOPY       additional utilities. Specifically, we found that dermoscopy
                              100
                                                                                        reduced provider perception of urgency for benign lesions
         TO ‘NON-URGENT’




                                                                                        such as verruca (Figure 2). Consequently, a greater propor-
                                                                                        tion of dermatologists in our study opted against prioritizing
                              50                                                        these patients for in-person evaluation. This is important in
                                                                                        the setting of the COVID-19 pandemic, as the risk of viral
                                                                                        exposure must be balanced with the benefits of office vis-
                               0                                                        its. Additionally, tele-dermoscopy may allow for better
                                                                                        resource utilization [14]. The ability to reduce the number
                                                                         TI T
                                                         TI N
                                    O S/




                                                                       AS N
                                                      AS IG
                                 AT U




                                                                                        of in-person visits allows for the care of a greater volume of
                                     RY




                                                           C




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                                                                                        patients and prevents unnecessary travel.
                            FL F




                                                                    M
                          IN IN




                                                    O
                                                  NE




                                                                                                   Thematic analysis of the moderated discussion revealed
                                                                                        that providers feel dermoscopic images are most useful for
Figure 2. Dermoscopy reduces perceived triage urgency for non-                          triaging malignant lesions and pigmented lesions, specifically
neoplastic lesions. The proportion of respondents that rated                            those with the most common morphological features. Inter-
non-neoplastic, benign neoplastic, and malignant neoplastic lesions                     estingly, despite improving providers’ abilities to correctly
as non-urgent before and after addition of dermoscopy is shown
                                                                                        classify malignant neoplastic lesions (Figure 1), the addition
above. Bar graphs illustrate the means. * indicates P < 0.05 at
                                                                                        of dermoscopy did not significantly affect urgency scores or
McNemar test.
                                                                                        management decisions. This may reflect the lack of consen-
                                                                                        sus amongst providers on the perceived urgency for treating
reduced access to dermoscopy during COVID-19 hampered                                   slow growing malignancies such as basal cell carcinoma [15].
tele-dermatology efforts. However, there was hesitancy to-                                         While training may be a limiting factor for the usefulness
wards direct-to-consumer dermoscopy.                                                    of dermoscopic images, study participants also voiced con-
                                                                                        cerns about the impact of image quality. The success of the

Conclusions                                                                             VISN 7 tele-dermatology program is in part due to imaging
                                                                                        protocols that ensure consistently high image quality. This
Our preliminary findings demonstrate that dermoscopy                                    involves staff training, imaging equipment, and additional
can be a useful adjunct when remotely triaging skin lesions.                            time—investments that are required for the success of future
This finding corroborates previous studies that suggest                                 tele-dermatology efforts [16].
dermoscopic images improve recognition of neoplastic le-                                           Our moderated discussion also revealed that participants
sions, particularly for pigmented lesions such as melanoma                              do not find dermoscopy useful for triaging widespread skin



4                                                                                                          Original Article | Dermatol Pract Concept. 2022;12(3):e2022129
  Table 2. Perceptions of dermoscopy for triage in tele-dermatology described by study participants,
                      presented by theme and subtheme with exemplary quotes.
      Theme and Subtheme                                                  Exemplary Quotes
 Utility of dermoscopy
 Useful for suspected malignancy        “Dermoscopy can be very useful for lesions suspicious for malignancy.”
 and pigmented lesions                  “(Dermoscopy) has a lot to add for pigmented lesions and neoplasms.”
 Useful for lesions with common         “Clear features can increase confidence; more obscure structures are less helpful.”
 dermoscopic morphologies               “There are certain things that I can trust dermoscopy for, like single lesions with
                                        specific findings.”
 Less useful for rashes (of note,       “Dermoscopy for limited portions of an exanthem, especially without history, can be
 there were no rashes included in       misleading.”
 the survey)                            “Clinical images are more reassuring and less confusing than dermoscopy for rashes.”
 Patient history complements            “I want to know the patient’s problem list and how acute this is relative to other
 dermoscopic images                     comorbidities.”
                                        “For example, if I see that this patient is immunosuppressed on the primary care note,
                                        that will change things.”
 Importance of image quality
                                        “If you have protocols for taking photos outlined, then that is more helpful. For the
                                        most part it’s going to be patients and nurses taking photos, so we need good protocols
                                        and feedback mechanisms in place, so protocols are followed.”
                                        “The lack of utility is based on both photo quality (such as extreme close ups, blurri-
                                        ness, lighting), as well as not knowing what to take photos of.”
 Increased accessibility to dermoscopy
 COVID19 limited availability to        “I felt handicapped [during COVID19] for neoplastic lesions, dermoscopy is crucial
 dermoscopic images                     for those.”
                                        “[The transition to telemedicine during COVID19] has made me realize the limitations
                                        of webcam and poor-quality images, which makes imaging protocols more important.”
 Hesitancy for consumer                 “I also worry that people might think they can interpret [dermoscopic images], which
 dermoscopy                             might be a problem. Even medical students don’t get formal training in dermoscopy.”
                                        “I’m skeptical about this technology in the hands of patients, but there might be utility
                                        for our high risk pigmented lesion patients.”



eruptions. They feel that it would save time and resources          (Table 1). While most (55%) of participants in our survey
to have primary providers submit dermoscopic images only            had training with at least 1 formal dermoscopy course, few
for appropriate cases. However, having primary providers or         dermatology residency programs provide formalized der-
patients determine which cases require dermoscopic images           moscopy training [19]. In the present study, participants had
is asking them to decipher skin eruptions from discrete skin        low self-reported confidence in their dermoscopic abilities,
lesions. In the present study, we included two cases in which       despite some with extensive use in their clinical practice. This
field actinic keratoses and field sebaceous hyperplasia were        may be attributed to the varying utilities of dermoscopy in
misidentified by the referring primary provider as general-         different contexts, for example, where participants felt der-
ized exanthems (Supplemental Table 1). It has been shown            moscopy was less useful for rashes (Table 2). The addition of
that primary care providers have difficulty diagnosing field        dermoscopy, nonetheless, proved useful for correctly triaging
actinic keratoses [17]. Accordingly, the tele-dermatology im-       benign and malignant skin lesions. These results and others
aging protocol at the VISN 7 Teledermatology service requires       suggest the benefits of dermoscopy could justify a standard-
clinical and dermoscopic images for every consult. While this       ized curriculum to be used across residency programs. This
requires more time and resources, it eliminates the possibility     educational gap must be addressed so that rising dermatol-
for this type of error. The ideal imaging protocol is likely de-    ogists are able to confidently use dermoscopy to its full po-
pendent on resources available at specific institutions. A pre-     tential [20-23].
vious study of digital imaging for tele-dermatology suggests            Our discussion revealed that providers are hesitant
that standardization should involve a panoramic photo, a            about consumer dermoscopy. There is concern that patients
close-up with measurements, and a dermoscopic image [18].           might start interpreting their own images, placing them at
    Our study participants had a wide and varied range              risk for mismanagement. This concern has been voiced by
of dermoscopy training and utilization in clinical practice         others as well [24]. However, studies have indicated that



Original Article | Dermatol Pract Concept. 2022;12(3):e2022129                                                                    5
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Original Article | Dermatol Pract Concept. 2022;12(3):e2022129                                                                               7
