Dermatoscopia Digital / Digital Dermoscopy

INTRODUCCIÓN La incidencia del melanoma cutáneo (MC) está aumentando en el mundo. Esta tendencia puede estar influenciada, entre otros, por el aumento en la exposición recreativa al sol, el uso de camas de bronceado y la existencia de una población cada vez más envejecida, que se ha visto expuesta a lo largo de su vida a la radiación ultravioleta con ese carácter recreativo mencionado previamente y las medidas adoptadas en materia sanitaria con una posible detección más temprana del MC. Se ha documentado también la existencia de factores de riesgo para el desarrollo de MC de la propia persona de índole genética y fenotípica. La prevención primaria es la medida más importante para limitar la aparición del MC, mediante el fomento de comportamientos que minimicen la exposición a las radiaciones ultravioletas y la aplicación regular de protec tores solares. La identificación del MC inicialmente precisa de un diagnóstico de sos pecha clínico que puede verse ap

INTRODUCTION The incidence of cutaneous melanoma (CM) is increasing worldwide. This trend may be influenced by, among others, the increase in recreational sun exposure, the use of tanning beds and the existence of an increasingly ageing population which has been exposed throughout its life to ultraviolet radia tion on a recreational basis as mentioned above and the health measures taken with possible earlier detection of CM. Genetic and phenotypic risk factors for the development of self-indu ced CM have also been documented. Primary prevention is the most important measure to limit the appea rance of CM, through the promotion of behaviours that minimise exposure to ultraviolet radiation and the regular application of sunscreens. The initial identification of CM requires a diagnosis of clinical suspi cion that can be supported by a range of diagnostic techniques. Dermatos copy is a widespread technique that requires a dermatoscope and is most widely used to examine pigmented skin lesions. It allows the display of skin structures that are not visible to the naked eye, reaching as far as the der moepidermal interface and upper dermis. Dermatoscopy requires minimal training and can be carried out using a manual dermatoscope (MD) or a digital dermatoscope (DD). The latter offers a higher magnification of the structures to be viewed and provides images that can be compared with each other during patient monitoring and even whole-body photographs of the person. The aim of this report is to analyse the diagnostic capacity of DD com pared to MD or with the combined use of both for the diagnosis of CM and its influence on subsequent clinical decision-making and patient health results, its efficiency and/or differences in the use of resources and costs, as well as to inform the population's experiences of a possible diagnosis of CM and the need to monitor their lesions. METHOD This assessment focused on comparing the diagnostic reliability of DD for CM with manual dermatoscopy plus photography (MD+P), its efficiency and the patients' values and preferences. A search of biomedical databases, a reverse search of selected studies and weekly active alerts were created up to the final edition of the report. Free and controlled language search terms were used. Initially defined study inclusion and exclusion criteria were followed for study selection. Study quality assessment tools were used and an initial work proposal was prepared using the GRADE method. RESULTS Seventeen publications were selected from 886 studies and a review of 76 full-text studies. After analysis, a qualitative approach was determined given the clinical and methodological heterogeneity identified between studies. Among the outcomes analysed, diagnostic accuracy in terms of sensiti vity and specificity for DD showed individual study estimates of between 17% and 100% and 20% and 98%, respectively, and with a reduction in false positives and an increase in false negatives as the prevalence of CM increases. From a scenario in which all lesions are referred for excision, it was found that the implementation of a new procedure in primary care with the possibility of using MD and DD, between 87.7% and 99.9% of pigmented malignant lesions and 84.7% and 99.9% of CM were properly managed. The results provided by the two selected studies reporting on the abili ty to identify early stage CM using the CM quotient in situ invasive CM or Breslow thickness show inconsistency and imprecision, respectively. From a study combining observation, MD and DD versus visual exa mination to diagnose CM, excision of benign lesions was reduced by bet ween 58% and 68.7%. The combined use of MD + DD in persons at high risk of CM allows for improved accuracy in taking decisions on whether to excise malignant lesions, with an increase in the percentage of CM among excised lesions at the expense of a reduction in the number of benign lesions excised. When persons are classified by their baseline risk of developing a CM, the combined use of MD and DD increases the probabilities of identifying CM in those at higher risk. In the general population, the combined use of MD and DD together with the experience of the healthcare professional increases the probabilities of identifying a CM by up to four times. Healthcare professionals' access to dermatoscopy improves their diag nostic confidence and certainty. People may accept and improve diagnostic confidence when DD is introduced into the care process but when faced with a hypothetical techno logy with 100% diagnostic accuracy, even with the best diagnostic methods such as MD and DD, these are underestimated in people's confidence by up to 40% compared to the hypothetical value. Compliance with the instructions given to persons to follow up their lesions is affected, for example, by waiting times in the clinic, the correct functioning of reminder systems and especially by the person's risk factors (the higher the risk, the better the compliance). The combined use of MD + DD can offer a statistically significant reduction in costs per split MC, with an estimated mean reduction in 2012 euros of €548 (95%CI: €65 to €1,856). Based on data from a study conducted in Australia for its health servi ce, the implementation of specialised care and monitoring of patients at high risk of CM with diagnostic support from DD would have a five-year cost saving of between 18.4 million euros and 15.3 million euros, depending on the chosen implementation modality (2017 euros). In the same healthcare scenario, the estimate of the average cost per person at high risk of CM during a 10-year monitoring was in favour of monitoring in specialised cen tres with access to DD and showed a gain in QALYs of 0.21 compared to standard monitoring in urban areas. There is no indication that the use of DD may affect the moral, cultu ral, religious or even beliefs of groups of persons. Some persons may feel uncomfortable with the need to obtain full body photographs. DISCUSSION While the results seem to suggest that the combined use of MD and DD in people at high risk of CM provides an improvement in the identification of CM, it should be noted that the clinical and methodological heterogeneity of the studies identified is high, so that the results should be interpreted with caution. Study design to meet the objectives of this report can be improved by considering how evidence can benefit or harm patients in guiding clinical decision-making and subsequent management, as well as the decision to order further tests or to start, stop or modify treatment, without losing sight of the emotional, social, cognitive and behavioural sphere of persons when faced with a diagnostic test that may identify them as a cancer patient. Dermatoscopy (any of its modalities) is a diagnostic technique for CM that could improve the early identification of CM, without losing sight of the fact that the results may be influenced by the person's compliance with the indications for monitoring their lesions. This may require taking into accou nt the individual's emotional state, which may be influenced by the test itself and by other elements surrounding the test such as the test procedure, the way in which the results are delivered, the type of follow-up examination or the waiting period for results. From an economic point of view, the results shown seem to be in favour of the combined use of MD and DD, especially in people at high risk of CM, without forgetting that these are results from contexts outside our national health system and, therefore, with a seriously compromised external validity. CONCLUSIONS In people without known risk factors, MD is the standard test for the identi fication of malignant pigmented lesions to be confirmed by pathological anatomy. Persons with high CM risk factors may benefit from initial diagnostic testing by MD or DD and monitoring by DD with closer monitoring inter vals over time. Initial screening and monitoring of individuals without high CM risk factors by DD does not provide better results in the identification of new pigmented lesions or observation of previous pigmented lesions compared to the use of MD. Based on low-quality tests, the monitoring of people at high or very high CM risk with the combined use of MD and DD proves to be cost effective in healthcare contexts other than the NHS. It would be desirable to have studies that assess the role of DD in the national health system from an economic perspective.

Implementation of artificial intelligence algorithms for melanoma screening in a primary care setting.

Skin cancer is currently the most common type of cancer among Caucasians. The increase in life expectancy, along with new diagnostic tools and treatments for skin cancer, has resulted in unprecedented changes in patient care and has generated a great burden on healthcare systems. Early detection of skin tumors is expected to reduce this burden. Artificial intelligence (AI) algorithms that support skin cancer diagnoses have been shown to perform at least as well as dermatologists' diagnoses. Recognizing the need for clinically and economically efficient means of diagnosing skin cancers at early stages in the primary care attention, we developed an efficient computer-aided diagnosis (CAD) system to be used by primary care physicians (PCP). Additionally, we developed a smartphone application with a protocol for data acquisition (i.e., photographs, demographic data and short clinical histories) and AI algorithms for clinical and dermoscopic image classification. For each lesion analyzed, a report is generated, showing the image of the suspected lesion and its respective Heat Map; the predicted probability of the suspected lesion being melanoma or malignant; the probable diagnosis based on that probability; and a suggestion on how the lesion should be managed. The accuracy of the dermoscopy model for melanoma was 89.3%, and for the clinical model, 84.7% with 0.91 and 0.89 sensitivity and 0.89 and 0.83 specificity, respectively. Both models achieved an area under the curve (AUC) above 0.9. Our CAD system can screen skin cancers to guide lesion management by PCPs, especially in the contexts where the access to the dermatologist can be difficult or time consuming. Its use can enable risk stratification of lesions and/or patients and dramatically improve timely access to specialist care for those requiring urgent attention.

Dermatoscopia digital para nevus displásico / Digital Dermatoscopy for Dysplastic Nevi

CONTEXTO CLÍNICO: Los nevos melanocíticos (lunares) son tumores melanocíticos benignos caracterizados por la proliferación de melanocitos que, a diferencia de los melanocitos normales, se agrupan en nidos cercanos a la unión dermoepidérmica. Sus principales problemas son el riesgo de transformación maligna, como es el caso de los nevos melanocíticos displásicos y el diagnóstico diferencial con melanoma. Los nevos displásicos son en su mayor parte planos y, con frecuencia, son más grandes que los lunares comunes, además tienen bordes desiguales. Un nevo displásico puede tener diferentes colores, que van desde el rosado hasta el marrón oscuro. Hay partes del lunar que pueden sobresalir de la superficie de la piel. Un nevo displásico puede volverse un melanoma (un tipo de cáncer de piel) y, cuantos más nevos displásicos tenga una persona, mayor es el riesgo de melanoma. Un nevo displásico también se conoce como lunar atípico o nevo atípico. Los nevos displásicos son relativamente comunes en la población general; la prevalencia oscila del 2 al 53% en diferentes estudios, dependiendo de los criterios diagnósticos tanto clínicos como histológicos. Se ha observado que la incidencia de melanoma es 15 veces mayor en pacientes con nevos clínicamente displásicos en comparación con la población en general. En personas con historia personal o familiar de melanoma, la presencia de nevos displásicos multiplica el riesgo por 100, y es posible que el 50% de ellas desarrollen algún melanoma antes de los 50 años. Para el abordaje clínico de lesiones pigmentadas sospechosas, se puede aplicar la regla mnemotécnica del ABCDE que es utilizada para la detección de melanoma. Se consideran lesiones atípicas si tienen dos o más de las siguientes características: una forma asimétrica (A = asimetría), bordes irregulares o policíclicos (B = bordes), colores variados (C = color), diámetro mayor a 5 mm (D = diámetro) y elevación de la lesión, con presencia simultánea de un componente de aspecto papular y macular (E = elevación). El síndrome de nevos displásicos fue descrito por Clark y colaboradores, y se caracteriza por la siguiente tríada: 1. presencia de 100 nevos o más, 2. al menos un nevo mayor de 8 mm con características clínicas atípicas, 3. pacientes con antecedentes familiares de melanoma.1,2 Según el NIH (National Institutes of Health) en el consenso de 1992, se considera como síndrome de nevo displásico cuando cumple con las siguientes características: 1. antecedentes de melanoma en uno o más familiares de primero o segundo grado, 2. más de 50 nevos melanocíticos, algunos de los cuales com características clínicas atípicas, y que existan alteraciones histológicas en varios de los nevos melanocíticos. La sensibilidad y especificidad de estos criterios para el diagnóstico clínico de nevos displásicos es de 58.4 y 66.6%, respectivamente. La distinción clínica entre lesiones pigmentadas malignas y benignas puede ser difícil en algunos casos. Sin embargo, con el uso de la dermatoscopia, método de diagnóstico no invasivo auxiliar en el examen dermatológico, es posible aumentar la exactitud del diagnóstico de las lesiones pigmentadas. La dermatoscopia (microscopía de superficie) es el examen de la piel con un sistema óptico y una fuente de luz diseñados para evaluar lesiones pigmentadas de la superficie cutánea. Así, es posible visualizar en profundidad estructuras, formas y colores que no son accesibles a simple vista. Existen dermatoscopias manuales y dermatoscopias digitales. Con el dermatoscopio manual (DM) el dermatólogo irá mirando los lunares uno a uno buscando los signos de malignidad del lunar. La dermatoscopia digital (DD) es una técnica no invasiva que permite la evaluación de imágenes dermatoscópicas con alta resolución, documentar las imágenes, grabarlas y verificar sus câmbios durante el tiempo, superponiendo y comparando las mismas; incrementando el rédito diagnóstico clínico y facilitando la diferenciación del M de otras lesiones pigmentadas benignas y malignas. TECNOLOGÍA: La dermatoscopia digital consta de una lente más luz polarizada que se encuentra conectado a un ordenador con una o más pantallas donde podemos ver las imágenes con gran detalle. La digitalización y archivo de las imágenes dermatoscópicas apuntan a aumentar la precisión diagnóstica, al permitir comparar imágenes durante el seguimiento de ciertas lesiones atípicas. En ocasiones, se detectan cambios imperceptibles para el ojo humano, que permiten hacer un diagnóstico muy precoz de melanoma, lo que es la mejor garantía para lograr su curación de la forma más sencilla posible. Los sistemas de DD pueden ser integrados o no integrados. Un sistema integrado implica que se puede disponer de todos los componentes en un solo equipo. Los equipos integrados que se utilizan con mayor frecuencia son Fotofinder® y Mole Max II®. Para la captación de imágenes se puede emplear una cámara de fotos o una videocámara. Esta última es la que se encuentra en los equipos integrados. La principal desventaja de las videocámaras es su baja resolución respecto a las cámaras digitales. Objetivo El objetivo del presente informe es evaluar la evidencia disponible acerca de la capacidad diagnóstica de la dermatoscopia digital para nevus melanocito displásicos. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas, en buscadores genéricos de internet, y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias (ETS), evaluaciones económicas, guías de práctica clínica (GPC) y políticas de cobertura de diferentes sistemas de salud. RESULTADOS: Se incluyeron una RS, ocho GPC y ocho informes de políticas de cobertura de dermatoscopia digital para nevus melanociticos displásicos. CONCLUSIONES: No hay estudios experimentales que hayan evaluado el beneficio clínico de la dermatoscopia en la incidencia o sobrevida de melanoma. Para la exéresis de lesiones, evidencia de moderada calidad sugiere que la adición de dermatoscopia manual o digital, a la inspección visual de nevus melanocíticos atípicos y/o melanomas, reduciría marcadamente la necesidad de exéresis diagnósticas. El uso de dermatoscopia digital aumenta la probabilidad de detectar lesiones que deben extirparse. Las guías de práctica clínica sugieren que la dermatoscopia debe usarse para el diagnóstico diferencial de lesiones pigmentadas de la piel y que la dermatoscopia digital debería usarse en pacientes de alto riesgo de desarrollar melanoma. Los diferentes financiadores de salud europeos, estadounidenses y latinoamericanos establecen el uso de dermatoscopia digital como medio de diagnóstico, seguimiento de lesiones como nevos displásicos para la prevención de desarrollo de melanoma en escaneos corporales totales, como ayuda para determinar márgenes de extirpación de nevus atípicos o lesiones compatibles con melanoma. Establecen que luego de una exéresis de una lesión o en caso que se requieran seguimientos más cercanos, éstos se realicen cada tres meses.

Identifying gram-positive cocci in dermatoscopes and smartphone adapters using MALDI-TOF MS: a cross-sectional study

Abstract Background: The increasingly frequent use of dermoscopy makes us think about the possibility of transfer of microorganisms, through the dermatoscope, between doctor and patients. Objectives: To identify the most frequent gram-positive cocci in dermatoscopes and smartphone adapters, as well as the resistance profile, and to evaluate the factors associated with a higher risk of bacterial contamination of the dermatoscopes. Methods: A cross-sectional study was carried out with 118 dermatologists from Porto Alegre/Brazil between September 2017 and July 2018. Gram-positive cocci were identified by MALDI-TOF MS and habits of use of the dermatoscope were evaluated through an anonymous questionnaire. Results: Of the dermatoscopes analysed, 46.6% had growth of gram-positive cocci on the lens and 37.3% on the on/off button. The microorganisms most frequently found were S. epidermidis, S. hominis and S. warneri. Attending a hospital, using the dermatoscope at the hospital, with inpatients and in the intensive care unit were significantly associated with colonisation by gram-positive cocci. The highest resistance rates were observed for penicillin, erythromycin and sulfamethoxazole-trimethoprim. Study limitations: The non-search of gram-negative bacilli, fungi and viruses. Moreover, the small number of adapters did not make it possible to better define if the frequency differences were statistically significant. Conclusion: Coagulase-negative staphylococci were frequently identified. S. aureus was detected only on the lens.

Identifying gram-positive cocci in dermatoscopes and smartphone adapters using MALDI-TOF MS: a cross-sectional study.

BACKGROUND: The increasingly frequent use of dermoscopy makes us think about the possibility of transfer of microorganisms, through the dermatoscope, between doctor and patients. OBJECTIVES: To identify the most frequent gram-positive cocci in dermatoscopes and smartphone adapters, as well as the resistance profile, and to evaluate the factors associated with a higher risk of bacterial contamination of the dermatoscopes. METHODS: A cross-sectional study was carried out with 118 dermatologists from Porto Alegre/Brazil between September 2017 and July 2018. Gram-positive cocci were identified by MALDI-TOF MS and habits of use of the dermatoscope were evaluated through an anonymous questionnaire. RESULTS: Of the dermatoscopes analysed, 46.6% had growth of gram-positive cocci on the lens and 37.3% on the on/off button. The microorganisms most frequently found were S. epidermidis, S. hominis and S. warneri. Attending a hospital, using the dermatoscope at the hospital, with inpatients and in the intensive care unit were significantly associated with colonisation by gram-positive cocci. The highest resistance rates were observed for penicillin, erythromycin and sulfamethoxazole-trimethoprim. STUDY LIMITATIONS: The non-search of gram-negative bacilli, fungi and viruses. Moreover, the small number of adapters did not make it possible to better define if the frequency differences were statistically significant. CONCLUSION: Coagulase-negative staphylococci were frequently identified. S. aureus was detected only on the lens.

Noninvasive Imaging Tools in the Diagnosis and Treatment of Skin Cancers.

In the 1980s, the increasing incidence of skin cancers prompted the development of noninvasive medical devices to improve skin cancer diagnosis in daily dermatology practice. As a result of the development of these noninvasive techniques, diagnosis is now established earlier and with better accuracy. These advances are of great benefit to high-risk patients, who previously would have had to undergo several excisions. In this review, we focus on the classic technique of dermoscopy and the more recent digital version, as well as on advanced noninvasive imaging techniques, such as reflectance confocal microscopy and optical coherence tomography. On the basis of their specific features, these noninvasive medical devices can be used not only to diagnose and monitor melanoma and nonmelanoma skin cancers but also to choose the best therapy and follow the patient's response to treatment in vivo.

Importancia del seguimiento de lesiones melanocíticas con dermatoscopia digital para el diagnóstico temprano de melanoma / Importance of monitoring melanocytic lesions with digital dermatoscopy for diagnosis early melanoma

La dermatoscopia digital es una herramienta que permite el diagnóstico de melanomas en estadios tempranos, por medio del seguimiento de las lesiones pigmentarias a largo plazo. Se comunican tres casos de pacientes con alto riesgo de melanoma, en los cuales ‒a través del seguimiento con dermatoscopia digital‒ se realizó el diagnóstico de la enfermedad mediante la detección de cambios morfológicos, arquitecturales y de pigmentación de las lesiones estudiadas. (AU)

Digital dermoscopy is a tool that allows the early diagnosis of melanomas, through the long-term follow up of pigmentary skin lesions. We report three cases of patients with high-risk of melanoma, in which the diagnosis had been made by morphological, arquitectural and pigmentary changes observed by the digital dermoscopy follow-up. (AU)

Application of dermoscopy image analysis technique in diagnosing urethral condylomata acuminata.

BACKGROUND: In this study, cases with suspected urethral condylomata acuminata were examined by dermoscopy, in order to explore an effective method for clinical. OBJECTIVE: To study the application of dermoscopy image analysis technique in clinical diagnosis of urethral condylomata acuminata. METHODS: A total of 220 suspected urethral condylomata acuminata were clinically diagnosed first with the naked eyes, and then by using dermoscopy image analysis technique. Afterwards, a comparative analysis was made for the two diagnostic methods. RESULTS: Among the 220 suspected urethral condylomata acuminata, there was a higher positive rate by dermoscopy examination than visual observation. STUDY LIMITATIONS: Dermoscopy examination technique is still restricted by its inapplicability in deep urethral orifice and skin wrinkles, and concordance between different clinicians may also vary. CONCLUSION: Dermoscopy image analysis technique features a high sensitivity, quick and accurate diagnosis and is non-invasive, and we recommend its use.

Application of dermoscopy image analysis technique in diagnosing urethral condylomata acuminata

Abstract: Background: In this study, cases with suspected urethral condylomata acuminata were examined by dermoscopy, in order to explore an effective method for clinical. Objective: To study the application of dermoscopy image analysis technique in clinical diagnosis of urethral condylomata acuminata. Methods: A total of 220 suspected urethral condylomata acuminata were clinically diagnosed first with the naked eyes, and then by using dermoscopy image analysis technique. Afterwards, a comparative analysis was made for the two diagnostic methods. Results: Among the 220 suspected urethral condylomata acuminata, there was a higher positive rate by dermoscopy examination than visual observation. Study limitations: Dermoscopy examination technique is still restricted by its inapplicability in deep urethral orifice and skin wrinkles, and concordance between different clinicians may also vary. Conclusion: Dermoscopy image analysis technique features a high sensitivity, quick and accurate diagnosis and is non-invasive, and we recommend its use.

Study of cutaneous cell carcinomas ex vivo using ultrasound biomicroscopic images.

BACKGROUND: The ultrasound biomicroscopy (UBM) technique generates high-resolution echographic images using acoustic frequencies between 20 and 200 MHz. In dermatology, it enables non-invasive visualization of cutaneous structures. In this sense, several studies are being conducted for the measurement of cutaneous tumor sizes and for the evaluation of their response to therapeutic procedures. The present work was conducted to analyze the ability of UBM to identify diverse histological structures associated with cutaneous carcinomas ex vivo regarding the evaluation of the technique as a diagnostic tool that could, eventually, improve the patient's healthcare protocol. METHODS: Ex vivo human tissue samples, corresponding to basal cell carcinoma and squamous cell carcinoma cases, were studied. The ultrasonic system operated with a center frequency of 45MHz and the histological structures were identified by comparison with the light microscopy images. RESULTS: The histological components present in the tumors were identified by variations in the echogenicity level for several of the studied cases and particular characteristics were observed for the different tumor types. CONCLUSION: The possibility of differentiating the histological components associated with cutaneous carcinomas indicates the potential use of UBM for diagnostic applications. However, a larger number of specimens must be studied.

Study of the dermatoscopic pattern of tinea nigra: report of 6 cases.

Digital dermatoscopy, a noninvasive auxiliary method that can improve the diagnosis of nearly all pigment skin lesions, was used to study 6 cases of tinea nigra, a rare dematiaceous superficial fungal infection and a potential mimicker of melanocytic nevus. Patients were first evaluated by a manual dermatoscope using a 10-fold magnification. The same patients were then reevaluated using a digital dermatoscope with 20-, 50-, and 70-fold magnifications. Direct mycologic examination and culture supported the establishment of the etiologic diagnosis. All reported cases showed a single dermatoscopic pattern. Manual and digital dermatoscopic images revealed irregularly distributed dark brown-pigmented dot lesions with filamentous aspect. The authors could not observe any melanocytic lesions. Cutaneous pigmented lesions, including superficial spreading melanoma, are the differential diagnosis. The dermatoscopic images are useful to help distinguish tinea nigra from other melanocytic diseases.