A Systematic Review of Diagnoses with Rosettes Under Dermoscopy.

INTRODUCTION: Rosettes are a cluster of shiny white dots in the shape of a four-leaf clover seen under polarized dermoscopic light. Historically, rosettes were primarily reported in actinic keratoses and squamous cell carcinoma. However, rosettes have also been reported in other conditions. OBJECTIVES: The objective of this systematic review to elucidate the breadth of diagnoses exhibiting this unique dermoscopic phenomenon. METHODS: A review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Literature searches were performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science, as well as a manual search of the reference lists of screened articles. RESULTS: A total of 73 articles met the inclusion criteria. Out of these, 47 distinct diagnoses with rosette were identified. Among neoplastic conditions, keratinizing neoplasms had the highest number of articles reported (N = 19). Discoid lupus was the most commonly reported diagnosis within the inflammatory category (N = 6). Molluscum contagiosum was the predominant diagnosis among infectious entities (N = 3), while acroangiodermatitis was the sole diagnosis reported in the vascular category (N = 1). CONCLUSIONS: These findings confirm rosettes are not specific to keratinocytic growths and are observed in a wide range of conditions. Knowledge of the breadth of conditions with rosettes may aid clinicians when developing a differential diagnosis of a growth or an eruption with rosettes under dermoscopy.

Thematic analyses of participant survey responses following dermatology ECHO programs with dermoscopy: Practical tips and lessons learned.

Introduction: Skin cancer is a major public health concern in the United States, reflecting approximately one in every three cancer diagnoses. Despite the high incidence of skin cancer, access to dermatologists is limited, especially in rural areas. Primary care physicians play a pivotal role in the evaluation of skin conditions, but dermatology training gaps exist in primary care training programs. Objectives: This study examines the use of the Project ECHO (Extension for Community Healthcare Outcomes) knowledge-sharing framework to provide dermoscopy and skin cancer detection training to primary care providers (PCPs). Methods: Responses to surveys administered to participants in two separate dermoscopy-focused Project ECHO courses were analyzed. Survey responses were collected over a 4-year period for the two courses, which were delivered in Maine and Texas. Thematic analysis of the qualitative data was performed, revealing codes and subcodes that indicated several overall trends. Results: Overall, most respondents indicated the ECHO sessions to be helpful, reporting an increase in confidence and knowledge in dermoscopy. Other codes reflected a positive reception of the learning materials and teaching styles. Furthermore, participant survey analyses highlighted areas of improvement for future ECHO course sessions. Conclusions: This thematic analysis of Project ECHO courses in dermatology with dermoscopy demonstrates the feasibility of using virtual educational platforms to effectively teach PCPs about dermoscopy and skin cancer, with high levels of participant satisfaction. The need to keeping the educational sessions brief, avoid scheduling sessions on high-volume patient care days, and provide a means for participants to obtain hands-on training in the operation of a dermatoscope were among the top lessons learned.

Early Detection and Prognostic Assessment of Cutaneous Melanoma: Consensus on Optimal Practice and the Role of Gene Expression Profile Testing.

Importance: Therapy for advanced melanoma has transformed during the past decade, but early detection and prognostic assessment of cutaneous melanoma (CM) remain paramount goals. Best practices for screening and use of pigmented lesion evaluation tools and gene expression profile (GEP) testing in CM remain to be defined. Objective: To provide consensus recommendations on optimal screening practices and prebiopsy diagnostic, postbiopsy diagnostic, and prognostic assessment of CM. Evidence Review: Case scenarios were interrogated using a modified Delphi consensus method. Melanoma panelists (n = 60) were invited to vote on hypothetical scenarios via an emailed survey (n = 42), which was followed by a consensus conference (n = 51) that reviewed the literature and the rationale for survey answers. Panelists participated in a follow-up survey for final recommendations on the scenarios (n = 45). Findings: The panelists reached consensus (≥70% agreement) in supporting a risk-stratified approach to melanoma screening in clinical settings and public screening events, screening personnel recommendations (self/partner, primary care provider, general dermatologist, and pigmented lesion expert), screening intervals, and acceptable appointment wait times. Participants also reached consensus that visual and dermoscopic examination are sufficient for evaluation and follow-up of melanocytic skin lesions deemed innocuous. The panelists reached consensus on interpreting reflectance confocal microscopy and some but not all results from epidermal tape stripping, but they did not reach consensus on use of certain pigmented lesion evaluation tools, such as electrical impedance spectroscopy. Regarding GEP scores, the panelists reached consensus that a low-risk prognostic GEP score should not outweigh concerning histologic features when selecting patients to undergo sentinel lymph node biopsy but did not reach consensus on imaging recommendations in the setting of a high-risk prognostic GEP score and low-risk histology and/or negative nodal status. Conclusions and Relevance: For this consensus statement, panelists reached consensus on aspects of a risk-stratified approach to melanoma screening and follow-up as well as use of visual examination and dermoscopy. These findings support a practical approach to diagnosing and evaluating CM. Panelists did not reach consensus on a clearly defined role for GEP testing in clinical decision-making, citing the need for additional studies to establish the clinical use of existing GEP assays.

Impact of Dermoscopy Training for Primary Care Practitioners on Number Needed to Biopsy to Detect Melanoma.

Introduction: The incidence of melanoma is on the rise. In trained hands, dermoscopy aids in the differentiation of melanoma from benign skin growths, including melanocytic nevi. This study evaluated the impact of dermoscopy training for primary care practitioners (PCPs) on the number of nevi needed to biopsy (NNB) to detect a melanoma. Methods: We conducted an educational intervention that included a foundational dermoscopy training workshop and subsequent monthly telementoring video conferences. We performed a retrospective observational study to evaluate the impact of this intervention on the number of nevi needed to biopsy to detect a melanoma. Results: The number of nevi biopsied to detect one melanoma decreased from 34.3 to 11.3 following the training intervention. Conclusion: Dermoscopy training for primary care practitioners resulted in a significant reduction in the NNB to detect melanoma.

Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care.

BACKGROUND: Primary care providers (PCPs) frequently address dermatologic concerns and perform skin examinations during clinical encounters. For PCPs who evaluate concerning skin lesions, dermoscopy (a noninvasive skin visualization technique) has been shown to increase the sensitivity for skin cancer diagnosis compared with unassisted clinical examinations. Because no formal consensus existed on the fundamental knowledge and skills that PCPs should have with respect to dermoscopy for skin cancer detection, the objective of this study was to develop an expert consensus statement on proficiency standards for PCPs learning or using dermoscopy. METHODS: A 2-phase modified Delphi method was used to develop 2 proficiency standards. In the study's first phase, a focus group of PCPs and dermatologists generated a list of dermoscopic diagnoses and associated features. In the second phase, a larger panel evaluated the proposed list and determined whether each diagnosis was reflective of a foundational or intermediate proficiency or neither. RESULTS: Of the 35 initial panelists, 5 PCPs were lost to follow-up or withdrew; 30 completed the fifth and last round. The final consensus-based list contained 39 dermoscopic diagnoses and associated features. CONCLUSIONS: This consensus statement will inform the development of PCP-targeted dermoscopy training initiatives designed to support early cancer detection.

A Pilot Educational Intervention to Support Primary Care Provider Performance of Skin Cancer Examinations.

Educational interventions to support Primary Care Provider (PCP) performance of skin cancer examinations typically train PCPs to "triage and refer," an approach that may result in diagnostic delays in regions without appropriate access to dermatology care. To address the needs of PCPs and patients in regions without appropriate access to dermatology care, we developed a multi-faceted pilot intervention, including a curriculum and telementoring, designed to support PCP performance of skin cancer detection examinations. Our intervention offers two levels of proficiency: "triage and refer" and "diagnose and manage." The pilot intervention was conducted in collaboration with the Texas Tech University of Health Sciences Center El Paso, TX Family and Community Medicine Department (TTUHSC-El Paso). Participation in the intervention was voluntary, and 18-22 family medicine resident physicians completed the intervention tests. The participating family medicine resident physicians demonstrated statistically significant gains in knowledge and self-efficacy at the immediate post-intervention time points. Further adaption of the pilot intervention is needed to meet the needs of practicing PCPs. The pilot tests require further adaption and validation. Translating education delivery from live/synchronous to interactive virtual/asynchronous modules will support greater educational dissemination, and telementoring support is essential to address challenging cases encountered during patient care.

The Role of Dermoscopy in Provider-to-Provider Store-and-Forward Dermatology eConsults: A Scoping Review of the Recent Literature.

Purpose of Review: This scoping review maps recent literature on dermatology provider-to-provider asynchronous store-and-forward (SAF) electronic consult (eConsult) platforms with dermoscopy. It offers a descriptive overview, highlighting benefits and challenges. Recent Findings: Incorporating dermoscopy into SAF eConsults improves diagnostic accuracy for benign and malignant skin neoplasms. Diagnostic and treatment concordance with traditional face-to-face (FTF) visits is high. SAF eConsults with dermoscopy enhance access to dermatological care by improving triage and reducing wait times for FTF visits. Pediatric patients benefit with improved evaluation of melanocytic and vascular growths. eConsult platforms with dermoscopy serve as a telementoring opportunity for clinicians interested in improving their dermoscopy skills. Summary: Adding dermoscopy to SAF eConsults is valuable and results in improved diagnostic accuracy and reduced need for FTF visits. Implementation barriers can be overcome through collaboration between primary care and dermatology. Dermoscopy in SAF eConsults has significant potential for managing skin conditions and reducing the burden caused by unnecessary FTF visit and biopsies.

Theory-Based Approaches to Support Dermoscopic Image Interpretation Education: A Review of the Literature.

Introduction: Efficient interpretation of dermoscopic images relies on pattern recognition, and the development of expert-level proficiency typically requires extensive training and years of practice. While traditional methods of transferring knowledge have proven effective, technological advances may significantly improve upon these strategies and better equip dermoscopy learners with the pattern recognition skills required for real-world practice. Objectives: A narrative review of the literature was performed to explore emerging directions in medical image interpretation education that may enhance dermoscopy education. This article represents the first of a two-part review series on this topic. Methods: To promote innovation in dermoscopy education, the International Skin Imaging Collaborative (ISIC) assembled a 12-member Education Working Group that comprises international dermoscopy experts and educational scientists. Based on a preliminary literature review and their experiences as educators, the group developed and refined a list of innovative approaches through multiple rounds of discussion and feedback. For each approach, literature searches were performed for relevant articles. Results: Through a consensus-based approach, the group identified a number of emerging directions in image interpretation education. The following theory-based approaches will be discussed in this first part: whole-task learning, microlearning, perceptual learning, and adaptive learning. Conclusions: Compared to traditional methods, these theory-based approaches may enhance dermoscopy education by making learning more engaging and interactive and reducing the amount of time required to develop expert-level pattern recognition skills. Further exploration is needed to determine how these approaches can be seamlessly and successfully integrated to optimize dermoscopy education.

Instructional Strategies to Enhance Dermoscopic Image Interpretation Education: a Review of the Literature.

Introduction: In image interpretation education, many educators have shifted away from traditional methods that involve passive instruction and fragmented learning to interactive ones that promote active engagement and integrated knowledge. By training pattern recognition skills in an effective manner, these interactive approaches provide a promising direction for dermoscopy education. Objectives: A narrative review of the literature was performed to probe emerging directions in medical image interpretation education that may support dermoscopy education. This article represents the second of a two-part review series. Methods: To promote innovation in dermoscopy education, the International Skin Imaging Collaborative (ISIC) assembled an Education Working Group that comprises international dermoscopy experts and educational scientists. Based on a preliminary literature review and their experiences as educators, the group developed and refined a list of innovative approaches through multiple rounds of discussion and feedback. For each approach, literature searches were performed for relevant articles. Results: Through a consensus-based approach, the group identified a number of theory-based approaches, as discussed in the first part of this series. The group also acknowledged the role of motivation, metacognition, and early failures in optimizing the learning process. Other promising teaching tools included gamification, social media, and perceptual and adaptive learning modules (PALMs). Conclusions: Over the years, many dermoscopy educators may have intuitively adopted these instructional strategies in response to learner feedback, personal observations, and changes in the learning environment. For dermoscopy training, PALMs may be especially valuable in that they provide immediate feedback and adapt the training schedule to the individual's performance.

Dermoscopy for the Identification of Amelanotic Acral Melanoma.

Acral lentiginous melanoma is commonly misdiagnosed, and when detected late it portends a poor prognosis. Acral lentiginous melanoma can be mistaken for verruca, pyogenic granuloma, poroma, an ulcer, or other benign skin conditions. Patients with acral skin growths often present initially to a podiatric physician or their primary care physician. It is at this point when the growth is triaged as benign or potentially malignant. Dermoscopy aids in this decision making. Historically, dermoscopy training has been geared toward dermatologists, but there is increasing recognition of the need for dermoscopy training in primary care and podiatric medicine. Dermoscopy is particularly helpful in pink (amelanotic) growths, which can lack the traditional clinical findings of melanoma. A literature review of acral melanoma and dermoscopy was performed in PubMed. We also describe a case of amelanotic acral melanoma in a 58-year-old with a rapidly enlarging painful mass on her heel. The lesion was initially thought to be a pyogenic granuloma and was treated with debridement (curettage). She was ultimately seen in the dermatology clinic, and the findings under dermoscopy were worrisome for amelanotic melanoma. Biopsy confirmed the diagnosis. The cancer metastasized, and the patient died less than 2 years later.

Evaluation of a pediatric dermatology electronic consult program in a rural state with subanalysis of infantile hemangioma cases.

An electronic consultation (e-Consult) store-and-forward teledermatology program was implemented to improve access to dermatologic care in Maine. While initially designed to triage potential skin cancers, we found this program to be heavily used for pediatric patients, especially infants. Our findings suggest e-Consult expedites care for pediatric dermatology patients, particularly those with infantile hemangiomas. The addition of dermoscopy to e-Consult platforms has the potential to expand e-Consult effectiveness.

Distance Learning and Spaced Review to Complement Dermoscopy Training for Primary Care.

BACKGROUND: Dermoscopy aids in skin cancer identification. For family physicians who use dermoscopy, there is higher sensitivity for melanoma detection than naked-eye examination. There is a shortage of dermoscopy training for primary care providers. The triage amalgamated dermoscopic algorithm (TADA) is designed for novice dermoscopists. While TADA can be taught in a short dermoscopy workshop, spaced review and blended learning strategies improve knowledge retention. OBJECTIVES: This study determined the impact that the addition of a distance learning platform has on clinical dermoscopy use. Moreover, it evaluated dermoscopic image identification (knowledge retention) following the addition of distance learning via Extension for Community Health Outcomes (ECHO) to a traditional TADA dermoscopy workshop. METHODS: Primary care providers voluntarily attended a 120-minute TADA dermoscopy workshop. Participants completed pre-intervention, post-TADA, and post-ECHO tests of 30 dermoscopic images of benign and malignant skin lesions. A survey was also administered to analyze clinical dermoscopy use and prior dermoscopy training. RESULTS: Twenty-seven residents, faculty, and advanced practice providers participated in this longitudinal observational cohort study. Mean test scores (out of 30) for images of benign and malignant lesions improved from 20.29 pre-intervention to 24.62 post-TADA and 27.63 post-ECHO (P < .001). On average, participants attended 4 ECHO sessions (out of 7 total) and there was a positive correlation (r = 0.77) between the number of ECHOs attended and post-ECHO scores. Dermoscope use increased from 37.0% to 96.3% (P < .001). CONCLUSION: Distance learning and spaced review complement dermoscopy workshop training for primary care.

Dermoscopy Proficiency Expectations for US Dermatology Resident Physicians: Results of a Modified Delphi Survey of Pigmented Lesion Experts.

Importance: Dermoscopy education in US dermatology residency programs varies widely, and there is currently no existing expert consensus identifying what is most important for resident physicians to know. Objectives: To identify consensus-based learning constructs representing an appropriate foundational proficiency in dermoscopic image interpretation for dermatology resident physicians, including dermoscopic diagnoses, associated features, and representative teaching images. Defining these foundational proficiency learning constructs will facilitate further skill development in dermoscopic image interpretation to help residents achieve clinical proficiency. Design, Setting, and Participants: A 2-phase modified Delphi surveying technique was used to identify resident learning constructs in 3 sequential sets of surveys-diagnoses, features, and images. Expert panelists were recruited through an email distributed to the 32 members of the Pigmented Lesion Subcommittee of the Melanoma Prevention Working Group. Twenty-six (81%) opted to participate. Surveys were distributed using RedCAP software. Main Outcomes and Measures: Consensus on diagnoses, associated dermoscopic features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for US dermatology resident physicians. Results: Twenty-six pigmented lesion and dermoscopy specialists completed 8 rounds of surveys, with 100% (26/26) response rate in all rounds. A final list of 32 diagnoses and 116 associated dermoscopic features was generated. Three hundred seventy-eight representative teaching images reached consensus with panelists. Conclusions and Relevance: Consensus achieved in this modified Delphi process identified common dermoscopic diagnoses, associated features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for dermatology residency training. This list of validated objectives provides a consensus-based foundation of key learning points in dermoscopy to help resident physicians achieve clinical proficiency in dermoscopic image interpretation.

A practical review of dermoscopy for pediatric dermatology part I: Melanocytic growths.

The value of dermoscopy in the detection of skin cancer is well established. Less is published on the utility of dermoscopy in the evaluation of pediatric skin disease. Our review (in two parts) aims to serve as an update on pediatric dermoscopy and to provide readers with a practical application for the use of dermoscopy in pediatric dermatology clinics. In part I, we propose a dermoscopy algorithm for pediatric skin disease and melanocytic growths, and in part II, we address vascular growths, common skin infections, and inflammatory conditions for which dermoscopy is valuable.

A practical review of dermoscopy for pediatric dermatology part II: Vascular tumors, infections, and inflammatory dermatoses.

In addition to the evaluation of melanocytic growths (Part I), dermoscopy is helpful in the identification and management of vascular tumors, skin infections, and inflammatory conditions. In this practical review, we present the classic dermoscopic findings of the following: vascular tumors, infectious conditions (molluscum contagiosum, scabies, verruca vulgaris), inflammatory conditions (psoriasis, atopic dermatitis), juvenile xanthogranuloma, and nevus sebaceus.

The many variants of psoriasis.

Erythema, skin thickening, and scales typify most cases, but other patterns exist. Tx choices may differ, depending on how much body surface area is covered.

Teaching Benign Skin Lesions as a Strategy to Improve the Triage Amalgamated Dermoscopic Algorithm (TADA).

INTRODUCTION: Dermoscopy aids family physicians (FPs) in skin cancer detection. The triage amalgamated dermoscopic algorithm (TADA) was created to simplify the dermoscopic evaluation of a skin growth. The purpose of this image-based study was to evaluate the effect of teaching the clinical and dermoscopic features of benign skin lesions on the diagnostic accuracy of skin cancer identification using TADA. We also sought to determine the best method to teach benign neoplasms. METHODS: In this cross-sectional study of an educational intervention, FPs participated in dermoscopy training. Participants were divided into 3 groups for teaching of common benign neoplasms (dermatofibroma, angioma, and seborrheic keratosis/lentigo): didactic + interactive, didactic + heuristic, and didactic. For each group, the benign teaching was followed by skin cancer identification training with TADA. All participants took a 30 image pre-test and 30 image post-test. RESULTS: Fifty-nine participants completed the study. The mean preintervention score (out of 30 correct responses) was 17.9 (SD, 4.5) and increased to 23.5 (SD, 3.0) on the postintervention evaluation (P < .001). Sensitivity for skin cancer increased from 62.5% to 88.1% following the intervention. Postintervention specificity for skin cancer was 87.8%. Sensitivity and specificity increased following the intervention for all 3 types of benign neoplasms. Diagnostic accuracy was not impacted by the method of benign teaching. CONCLUSION: Short dermoscopy training sessions with dedicated time for benign growths followed by TADA training for malignant growths are an effective means of teaching FPs dermoscopy and result in a high sensitivity and specificity for the identification of benign and malignant skin neoplasms.

Progressive discoloration over the right shoulder.

The discolored patch on our patient's shoulder was nothing new-but when it grew in size and developed hypertrichosis, it prompted a closer investigation.