10.5826/dpc.1301a31
Introduction: Access to dermatology specialty care is limited in the underserved population. Barrier identification and exploring the potential role of teledermatology are the first steps to address this problem. 
Objectives:  Identify the barriers to dermatologist care for diagnosis and treatment of melanoma and non-melanoma skin cancers in the underserved population.  Additionally explored was the potential role of teledermatology to provide dermatology care access in the underserved population.  
Methods:  A quantitative descriptive study was conducted via an online survey instrument.  The survey’s barriers portion was adapted from the 1998 Ohio Family Health Survey (OFHS).  The survey’s teledermatology portion was adapted from the McFarland Teledermatology Provider and Imaging Technician Satisfaction Survey.  The participants were practicing dermatologists and members of Georgia, Missouri, Oklahoma, and Wisconsin dermatology associations.  Thirty-eight responded to demographic questions, of which twenty-two responded to the survey items.  
Results: The top three barriers ranked as the most concerning were continually uninsured (n = 8; 36.40%), resides in a medically underserved county (n = 5; 22.70%), and family under federal poverty level (n = 7; 33.30%).  Teledermatology as a potential role for access to care was supported by convenient delivery of healthcare (n = 6; 72.70%), an addition to regular patient care (n = 20; 90.90%), and increase to patient care access (n = 18; 81.80%). 
Conclusion:  Barrier identification and teledermatology access to provide care to the underserved population is supported. Further teledermatology research is necessary to address the logistics regarding how to initiate and deliver teledermatology to the underserved.
text/xml
2160-9381
2461
en
Darlla Duniphin
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Skin Cancer
Limited Access to Dermatology Specialty Care:  Barriers and Teledermatology
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-03-13
2023-01-31
2023-02-27
e2023031
Dermatol Pract Concept
Introduction: Access to dermatology specialty care is limited in the underserved population. Barrier identification and exploring the potential role of teledermatology are the first steps to address this problem. 
Objectives:  Identify the barriers to dermatologist care for diagnosis and treatment of melanoma and non-melanoma skin cancers in the underserved population.  Additionally explored was the potential role of teledermatology to provide dermatology care access in the underserved population.  
Methods:  A quantitative descriptive study was conducted via an online survey instrument.  The survey’s barriers portion was adapted from the 1998 Ohio Family Health Survey (OFHS).  The survey’s teledermatology portion was adapted from the McFarland Teledermatology Provider and Imaging Technician Satisfaction Survey.  The participants were practicing dermatologists and members of Georgia, Missouri, Oklahoma, and Wisconsin dermatology associations.  Thirty-eight responded to demographic questions, of which twenty-two responded to the survey items.  
Results: The top three barriers ranked as the most concerning were continually uninsured (n = 8; 36.40%), resides in a medically underserved county (n = 5; 22.70%), and family under federal poverty level (n = 7; 33.30%).  Teledermatology as a potential role for access to care was supported by convenient delivery of healthcare (n = 6; 72.70%), an addition to regular patient care (n = 20; 90.90%), and increase to patient care access (n = 18; 81.80%). 
Conclusion:  Barrier identification and teledermatology access to provide care to the underserved population is supported. Further teledermatology research is necessary to address the logistics regarding how to initiate and deliver teledermatology to the underserved.
Darlla Duniphin
2023/01/31
10.5826/dpc.1301a31
e2023031
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
2160-9381
Skin Cancer
en
e2023031
Skudalski L, Waldman R, Kerr P, et al. Melanoma: How and when to consider clinical diagnostic technologies. Journal of the American Academy of Dermatology. 2022;86(3):503-512. https://doi.org/10.1016/j.jaad.2021.06.90
Limited Access to Dermatology Specialty Care:  Barriers and Teledermatology
https://dpcj.org/index.php/dpc/article/download/2461/1936
       Limited Access to Dermatology Specialty Care:
               Barriers and Teledermatology
                                                     Darlla D. Duniphin1,2


1 University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
2 A.T. Still University, Mesa, Arizona, United States



Key words: barriers, teledermatology, melanoma, non-melanoma, skin cancer
Citation: Duniphin DD. Limited Access to Dermatology Specialty Care: Barriers and Teledermatology. Dermatol Pract Concept.
2023;13(1):e2023031. DOI: https://doi.org/10.5826/dpc.1301a31
Accepted: April 17, 2022; Published: January 2023
Copyright: ©2023 Duniphin. 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.
Corresponding Author: Darlla D. Duniphin, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States,
E-mail: darlla-duniphin@ouhsc.edu




  ABSTRACT             Introduction: Access to dermatology specialty care is limited in the underserved population. Barrier
                       identification and exploring the potential role of teledermatology are the first steps to address this
                       problem.
                       Objectives: Identify the barriers to dermatologist care for the diagnosis and treatment of melanoma
                       and non-melanoma skin cancers in the underserved population. Additionally explored was the poten-
                       tial role of teledermatology to provide dermatology care access in the underserved population.
                       Methods: A quantitative descriptive study was conducted via an online survey instrument. The sur-
                       vey’s barriers portion was adapted from the 1998 Ohio Family Health Survey (OFHS). The survey’s
                       teledermatology portion was adapted from the McFarland Teledermatology Provider and Imaging
                       Technician Satisfaction Survey. The participants were practicing dermatologists and members of Geor-
                       gia, Missouri, Oklahoma, and Wisconsin dermatology associations. Thirty-eight responded to demo-
                       graphic questions, of which twenty-two responded to the survey items.
                       Results: The top three barriers ranked as the most concerning were “continually uninsured” (n = 8;
                       36.40%), “resides in a medically underserved county” (n = 5; 22.70%), and “family under federal
                       poverty level” (n = 7; 33.30%). Teledermatology as a potential role for access to care was supported
                       by convenient delivery of healthcare (n = 6; 72.70%), an addition to regular patient care (n = 20;
                       90.90%), and increase to patient care access (n = 18; 81.80%).
                       Conclusion: Barrier identification and teledermatology access to provide care to the underserved pop-
                       ulation is supported. Further teledermatology research is necessary to address the logistics regarding
                       how to initiate and deliver teledermatology to the underserved.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023031                                                                      1
Introduction                                                          Objectives
Access to dermatology specialty care is limited in the un-            The purpose of this quantitative descriptive research study
derserved population and is related to patient socioeco-              was to identify the barriers to dermatologist care for diagno-
nomic status, rural residence status, and provider location           sis and treatment of melanoma and non-melanoma skin can-
­distribution [1]. Melanoma and non-melanoma skin cancer              cers in the underserved population. Additionally explored
in the underserved population have public health repercus-            was the potential role of teledermatology to provide access
sions that include poor patient outcomes directly associated          to this care in this population.
with late-stage diagnoses [2]. Barrier identification and der-
matology access are the first steps to address the dermato-
                                                                      Methods
logical needs of the underserved population. It is estimated
that a 16% increase will occur between 2013 and 2025 for              The research design was a quantitative descriptive study
dermatology visits [3]. There are approximately 3.4 derma-            via a survey instrument. The study participants were prac-
tologists per 100,000 population, which is lower than what            ticing dermatologists who were members of either Georgia,
is needed to provide adequate dermatology care in commu-              Missouri, Oklahoma, or Wisconsin dermatology associa-
nities [4]. This overall dermatology access shortage includes         tions. The respective state dermatology associations sent
67.10% in dedicated medical dermatology patient care time             the surveys to the memberships. The accessible population
[5].The combination of the rise in skin cancer rates, extended        included 700 dermatologists. The estimate of this popula-
wait times, increased need for dermatology visits, and the            tion size with a confidence level of 95%, a margin of er-
shortage of practicing dermatologists prompts a valid public          ror at 5%, and the estimated 10% response rate indicates
health concern. This concern is exacerbated by barriers to            248 participant responses was the optimal sample size [8].
care for the underserved. Innovative methods are necessary            A total of 38 responded to demographic questions, of which
for patients to have sufficient access to dermatologist care [5].     22 responded to the survey items. The cover letter served
    Teledermatology allows providers to diagnose and rec-             as the survey participation invitation with the inserted Sur-
ommend treatment and address the limited dermatology spe-             veyMonkey link. Survey responses were anonymous with
cialty care access in the underserved population. One of the          computer password protection. The survey data collection
main teledermatology applications is to triage dermatology            range was February 2019 – April 2019. The inclusion cri-
patients with higher morbidity and mortality risks to facil-          teria were (a) a practicing dermatologist who is a member
itate earlier in-person visits [6]. This access accommodates          of his or her respective state dermatology association in the
early detection of potentially lethal dermatological diseases         states of Georgia, Missouri, Oklahoma or Wisconsin; and
such as melanoma and non-melanoma skin cancers. The                   (b) between the ages of 25 through 64. The exclusion crite-
barrier-focused framework included patient income, lack               ria were (a) a non-practicing dermatologist in any state and
of insurance, and where the underserved population seeks              (b) below the age of 25 or above the age of 64. The sampling
health care. The poor, those who live in rural areas, and high        methodology was quantitative. The sampling methodology
minority locations lack access to dermatologists [1]. There           was non-probability consecutive sampling.
is a need for additional research-tested programs for der-               The barriers portion of the survey was adapted from
matologic treatment for underserved communities [2]. To               the 1998 Ohio Family Health Survey (OFHS), which was
address and explore potential treatment intervention pro-             developed through the Ohio Department of Health [9]. Ten
grams, barrier identification for dermatologist care of skin          rank-order barriers were adapted regarding access to der-
cancers in the underserved population is necessary in clos-           matological specialty care. Permission to use and adapt the
ing the gap of dermatologic specialty care of melanoma and            data collection tool, “McFarland Teledermatology Provider
non-­melanoma skin cancers to the underserved population.             and Imaging Technician Satisfaction Survey” was requested,
Current research also includes the use of teledermatology             approved, and received by the author Dr. Lynne McFarland.
for general dermatology care; however, there is a scarcity of         Nineteen items on a 5-point Likert scale were adapted for
teledermatology to provide access for diagnosis and treat-            the teledermatology items. The demographic portion of the
ment of melanoma and non-melanoma skin cancers in the                 survey included dichotomous, classificatory, and rank-order
underserved population.                                               responses. The demographics included age, sex, degrees,
    Early detection that leads to earlier diagnosis and treat-        income, and race. Also included in the demographics were
ment of melanoma and non-melanoma skin cancers im-                    practice setting, practice-setting location, and if the partici-
proves patient care outcomes and reduces morbidity and                pant had received training in teledermatology.
mortality [7]. Barrier identification is the first step to find and      The validity and reliability of the “McFarland Teleder-
improve interventions to address and resolve these obstacles.         matology Provider and Imaging Technician Satisfaction



2                                                                         Original Article | Dermatol Pract Concept. 2023;13(1):e2023031
Survey” was based on the validated PSQ originally devel-          private (n = 24; 96.00%), and the location setting majority
oped by Ware et al. that classifies similar items [10]. The       was suburban practice (n = 15; 60.00%). Most dermatolo-
questions were from a standardized, validated, and reliable       gists did not have teledermatology training (n = 14; 56.00%)
instrument (Cronbach’s alpha = 0.72-0.92 over the domains         (see Table S1).
for internal consistency) and construct validity regarding           Research question 1. The first research question ad-
multiple patient settings. According to McFarland, this in-       dressed the rank-ordering of the barriers to dermatologist
strument was for telemedicine in general, but not specifically    care for the diagnosis and treatment of melanoma and
teledermatology. McFarland’s questions were dermatologist         non-melanoma skin cancers in the underserved popula-
and medical provider vetted for concerns and satisfaction ar-     tion. Ten barriers were rank-ordered by the respondents in
eas [10]. The satisfaction domains were recommended by a          order of greatest to least concerning barrier (see Table S2).
review of Kraai et al. telemedicine satisfaction surveys [10].    The top three barriers ranked as the most concerning were
Two dermatologist subject-matter experts were enlisted to         “continually uninsured” (n = 8; 36.40%), “resides in a med-
establish face and content validity for this study’s survey.      ically underserved county” (n = 5; 22.70%), and “family
The feedback included the addition of the practice setting to     under federal poverty level” (n = 7; 33.30%), respectively
specify academic, private, or hospital, and the practice set-     (see Table S3).
ting location to specify urban, rural, or suburban. Feedback         Research question 2. The second research question ad-
also included if the participant had teledermatology training.    dressed the potential role of teledermatology in providing
    Descriptive statistical analysis was conducted using IBM      access to dermatologist care for the diagnosis and treatment
SPSS Statistics Version 25. Frequencies and percentages were      of melanoma and non-melanoma skin cancers in the under-
reported for nominal demographic variables. Frequencies,          served population. The respondents rated each statement
percentages, median, and IQR were reported for ordinal de-        on a 5-point Likert scale ranging from strongly disagree =
mographic variables. Ratio level data were tested for nor-        1 to strongly agree = 5. The scale ratings were collapsed to
mality using the Shapiro-Wilk test (α <.05) and the median        produce a dichotomous response for each statement item.
and IQR were reported. The barriers were rank-ordered             Strongly disagree and disagree were combined as well as
with frequencies and percentages noted. A 5-point Likert          strongly agree and agree were combined. No opinion was
scale was used to rate the responses of the teledermatology       removed from the analysis results to maintain dichotomous
items. Because the statements were adapted from a standard-       results (see Table S4).
ized data collection instrument and not all of the original          This study found that the major barriers to the diagnosis
questions were included, an item-by-item analysis was con-        and treatment of melanoma and non-melanoma in the un-
ducted. Frequencies and percentages were reported for the         derserved population were related to insurance status, med-
teledermatology items as well. Findings for rank-ordered          ically underserved county residence, and income level. The
barriers and teledermatology items were included both in          greatest barrier was “continually uninsured patients”, fol-
text and in a tabular format.                                     lowed by “resides in a medically underserved county”, and
                                                                  “family under federal poverty level”. The results regarding

Results                                                           the barriers of “resides in a medically underserved county”,
                                                                  and “family under federal poverty level” support the research
An estimated 700 potential participants received the survey       by Vaidya1 that the poor access to dermatology specialty care
via the four dermatologist societies. Thirty-eight participants   in the underserved population is related to patient socioeco-
responded to demographic questions. Of the 38 respondents,        nomic status, rural residence, and provider location distribu-
22 responded to the survey items. The remaining 16 surveys        tion. Research results by Campagna et al. [11] additionally
were excluded due to not meeting inclusion criteria or not        support that limited access to dermatology specialists is due
answering the barrier or teledermatology item sets. The           to rural residence and socioeconomic barriers in the under-
approximate number of participants that received surveys          served population. The highest-ranked barrier of continually
was 700, which represents a 5.43% overall response rate.          uninsured identified in this study supports the research of
The complete survey response rate was 3.14%. Testing for          Nelson et al. [12] that uninsured, Medicaid, and rural pa-
normality for the age demographic was completed by using          tients have increased wait times for dermatology office visits.
the Shapiro-Wilk test (p = .005). The median age was 54           The appointment waiting time for this population to see a
(IQR = 17) years (see Table S1). The majority of the re-          dermatologist delays diagnosis and subsequent treatment.
spondents were male (n = 13; 54.20%), and most held MD            This result is also supported by the research of Pasquali et al.
degrees (n = 25; 65.80%). Annual income was tested for nor-       [13] that a benefit of teledermatology provided dermatology
mality using the Shapiro-Wilk test. The median income was         specialty care access to patients in remote areas and patients
$200,000 or more (IQR = 0). Most practice settings were           on long waiting lists.



Original Article | Dermatol Pract Concept. 2023;13(1):e2023031                                                                  3
    The conceptual barrier-focused framework included the         work. The findings in this study showed that the preference
lack of insurance, where the underserved population seeks         was face-to-face patient visits over teledermatology, and the
healthcare access, and patient income, which was supported        lack of physical contact for the physical exam was a concern.
by this study’s findings. The status of the patients’ health,     These results did not support McFarland, which reports a
insurance, and income was among barriers associated with          slight preference for teledermatology over face-to-face visits,
the lack of a regular healthcare source [9]. Barrier identifi-    as well as the lack of physical contact, which was sufficient.
cation is the first step to resolve access and care. Innovative   The results of this study included the recognition of the need
methods are necessary for patients to have sufficient access      for access and care for the underserved population, which
to dermatologist care [5].                                        supported Jacobsen et al. [2] showing there is a need for ad-
    This study also found that the role of teledermatology        ditional research-tested programs for the treatment of the
in providing access to dermatological specialty care for di-      underserved population.
agnosis and treatment of melanoma and non-melanoma is                The sample size of this study was relatively small com-
a viable option in the underserved population. This finding       pared to the number of U.S. dermatologists. The small
supports Levitt et al. [6] that using teledermatology in the      sample size limits the generalizability of this study, and the
underserved population increases access to care for this pop-     results are suggestive to the population.
ulation. The results of this study found that dermatologists         The findings of this study identified and rank-ordered
agreed regarding the ability to describe and assess derma-        the barriers to the diagnosis and treatment of melanoma and
tology diagnoses and treatment needed as well as monitor          non-melanoma skin cancers in the underserved population.
the patients’ conditions via teledermatology. These findings      These identified findings can be addressed by healthcare pro-
agree with Leavitt et al. [6] that teledermatology contrib-       viders and administrators to begin to overcome these barriers
utes to accurate diagnoses with consistency. Teledermatol-        for patients. The results also indicate that there is a potential
ogy could increase access to dermatology care, which would        role for teledermatology to provide access to dermatology
ease the ability for patients to contact a dermatologist. The     specialty care. These findings can also be used by healthcare
increase in access is supportive of earlier patient care, which   providers and administrators to not only address the barriers
could benefit earlier skin cancer detection. These results        but to begin the logistical and financial process to provide
also support the premise of Apalla et al. [7] that early de-      teledermatology services. By opening the dialogue of barrier
tection leads to early diagnosis and treatment of melanoma        identification and teledermatology potential, dermatology
and non-melanoma skin cancers and improves patient care           diagnosis and treatment of melanoma and non-melanoma
outcomes, reducing morbidity and mortality. Research by           skin cancers can result in better patient care and outcome.
Fludiona et al. [14] provides additional support regarding           A limitation of this study was the small sample size,
early detection, reporting that suspicious neoplasms were         which reduced the generalizability of the study results. The
the top diagnosis that recommended accelerated face-to-face       sampling method was also a limitation, as it did not reach
consultation for teledermatology patients. Teledermatology        a large enough number of practicing dermatologists. Due
is the clinical diagnostic technology of choice for patients      to the time allotted for this study, a limitation was also ad-
who have concerning lesions with access barriers to care per      dressing two different research questions as opposed to one.
Skudalski et al. [15].                                            Even though they are related to each other, separate studies
    Teledermatology was found to be a convenient form of          would allow greater focus and more in-depth research for
healthcare delivery and a standard form of healthcare deliv-      each question.
ery for the future. These results support Nelson et al. [12]         Recommendations for future research include attempt-
that teledermatology complements outpatient dermatology           ing to resolve the limitations discussed for this study, such
healthcare delivery. This study found that dermatologists         as obtaining a larger sample size by additional participant
were willing to add teledermatology to the regular patient        requests and devoting more research time. A recommenda-
care received and agreed there was no threat to patient con-      tion for research includes exploring the logistics and costs
fidentiality and privacy. These results support McFarland         associated with providing teledermatology to the under-
et al. [10] also showing majority agreement in the same areas.    served as well as patient transportation for follow up face-
The results of this study indicated that the logistics of using   to-face visits. The cost and payment of treatment, how to
the camera and computer in teledermatology were not diffi-        initially launch teledermatology, and operational require-
cult; however, trusting the equipment to work was a concern.      ments also need to be researched to address the need for
These results were in agreement with McFarland regarding          care of the underserved. This research process has shown
whether the equipment was easy to use; however, it was in         that each item identified opens up new avenues to be ex-
opposition regarding whether the equipment was trusted to         plored and studied.




4                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e2023031
Conclusion                                                                4. Glazer AM, Rigel DS. Analysis of trends in geographic dis-
                                                                             tribution of US dermatology workforce density. JAMA
The purpose of this study was to identify the barriers to the                Dermatology. 2017; 153(5): 472. https://doi.org/10.1001
                                                                             /jamadermatol.2016.6032.
diagnosis and treatment of melanoma and non-melanoma
                                                                          5. Buster KJ, Stevens EI, Elmets CA. Dermatologic health dis-
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ally uninsured”, “resides in a medically underserved county”,                to improve access to care for medically underserved popula-
and “family under federal poverty level”, prompt the need for                tions: A retrospective descriptive study. Journal of the American
                                                                             Academy of Dermatology. 2016;75(6):1259-1261. https://doi
additional research to address and overcome these barriers.
                                                                             .org/10.1016/j.jaad.2016.07.043.
These barriers raise public issues of affordable health care,             7. Apalla Z, Lallas A, Sotiriou E, et al. Epidemiological trends in
healthcare provider incentive to practice in underserved loca-               skin cancer. Dermatology Practical & Conceptual. 2017;7(2).
tions, and the effect of poverty regarding healthcare. There is           8. Sample size table. (n.d.). Retrieved from http://researchadvisors
support for the potential role of teledermatology to provide                 .com/tools/SampleSize.htm.
dermatology care for the underserved. Even though derma-                  9. Litaker D, Koroukian SM, Love TE. Context and health-
                                                                             care access: Looking beyond the individual. Medical Care4.
tologists did prefer face-to-face visits over teledermatology as
                                                                             2005;3(6):531-540. https://doi.org/10.1097/01.mlr.0000163642.
well as a concern for lack of physical contact, the remaining                88413.58.
results support teledermatology use. Access barriers are also            10. McFarland LV, Raugi GJ, Reiber GE. Primary care provider and
concerning in other countries including India, Madagascar,                   imaging technician satisfaction with a teledermatology project
and Senegal due to a low dermatologist-to-population ratio.                  in rural Veterans Health Administration clinics. Telemedicine
[13]. In addition to identifying barriers to specialty dermatol-             and e-Health. 2013;19(11):815-825. https://doi.org/10.1089
                                                                             /tmj.2012.0327.
ogy access for the underserved population, teledermatology
                                                                         11. Campagna M, Naka F, Lu J. Teledermatology: An updated
includes training to cover basic dermatological conditions on                overview of clinical applications and reimbursement policies.
a global scale [13]. Within the scope of this study, the access-             International Journal of Women’s Dermatology. September
to-care barriers regarding general skin care versus specialty                2017;3(3):176-179. https://doi.org/10.1016/j.ijwd.2017.04.002
dermatological care are the same, as the focus is in regards             12. Nelson CA, Takeshita J, Wanat KA, et al. Impact of
to the underserved population. Further research is needed to                 store-and-forward (SAF) teledermatology on outpatient der-
                                                                             matologic care: A prospective study in an underserved urban
address the logistics to initiate and deliver teledermatology
                                                                             primary care setting. Journal of the American Academy of Der-
to the underserved, as well as the costs to provide access,                  matology. 2016;74(3):484-490.e1. https://doi.org/10.1016/j
treatment cost, and patient transportation. In summary, iden-                .jaad.2015.09.058.
tifying the barriers as the first step to providing dermatology          13. Pasquali P, Sonthalia S, Moreno-Ramirez D, et al. Telederma-
care for the underserved raises the need for more research                   tology and its current perspective. Indian Dermatology Online
to address and find resolutions. The role of teledermatology                 Journal. 2020;Jan-Feb;11(1):12-20. https://doi.org/10.4103/idoj
                                                                             .IDOJ_241_9
to provide access is supported, but there is also a need for
                                                                         14. Fludiona N, Jun L, Porto A, et al. Impact of dermatology eCon-
further research to explore the logistics and costs to provide               sults on access to care and skin cancer screening in underserved
this service to the underserved.                                             populations: A model for teledermatology services in com-
                                                                             munity health centers. Journal of the American Academy of
Acknowledgment: Helen Salisbury, PhD, A.T. Still Univer-                     Dermatology. 2018;78(2):293-302. https://doi.org/10.1016/j
sity, Mesa, Arizona, United States                                           .jaad.2017.09.017
                                                                         15. Skudalski L, Waldman R, Kerr P, et al. Melanoma: How and
                                                                             when to consider clinical diagnostic technologies. Journal of
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Original Article | Dermatol Pract Concept. 2023;13(1):e2023031                                                                              5
