Skin cancer incidence and mortality continues to rise. Public health campaigns are raising patient concerns about skin lesions.
As a result, practitioners in primary care are understandably anxious to avoid missing melanomas. This has led to an increase in referrals, placing pressure on dermatology services. It therefore makes good sense for primary care doctors to develop better lesion recognition skills.
The dermoscope is analogous to the stethoscope, which is applied to the chest only after taking a history and performing a more general examination.
There is a large amount of disturbing melanoma-related material on the internet, including blogs by people who are dying from their melanomas, obituaries of deceased melanoma patients, explicit images of fungating cancer, CT scans showing brain deposits etc.
Patients doing an internet search on ‘melanoma’ or ‘skin cancer’ will find this material in 3 or 4 clicks. Some will come across this material while they are waiting for their appointment at the skin cancer clinic. Those who have benign lesions such as seborrhoeic keratoses or haemangiomas may have become extremely worried, unnecessarily.
A doctor trained in dermoscopy will normally be able to confirm, within a few minutes, whether or not a lesion is benign. Being able to provide confident reassurance that a pigmented lesion is benign, where this can be done safely, does not merely save money and hospital resources and patient time, but also a lot of needless anxiety.
However, the fact remains that the fascinating art of dermoscopy has not caught on as fast as it might have done, despite a strong and growing published evidence base for its efficacy. One objection to introducing dermoscopy into routine clinical practice is that this might create more confusion, since primary care doctors continue to receive inadequate training in even the basics of skin lesion recognition. This is a reasonable concern.
However, it is hoped that the growing interest in dermoscopy, fuelled by concern about skin cancer (especially melanoma), will lead to a general improvement in medical undergraduate, nurse and physician training in skin lesion recognition.
In the UK, melanoma is killing more than twice as many people as cancer of the cervix, and yet tuition on lesion recognition is typically allocated a mere 6 hours or so at medical school, and around 3 hours during general practitioner (primary care) training.
Our patients have the right to expect better than this. This book is humbly offered as a small contribution to that end.
It is calculated from international melanoma survival statistics that if melanoma mortality in the UK could be reduced to the level achieved in Australia, this could save more than 500 lives a year. The reduction in expenditure on melanoma chemotherapy alone could easily pay for the necessary training. The same general principles most likely apply around the world.
Finally, to put the role of dermoscopy in perspective, there are five aspects to skin lesion diagnosis and triage:
- Firstly, the natural history of common and important lesion types, including their range of presentations, must be learned.
- Next, a good history must be taken, after which an examination of the lesion is made (preferably also of the whole skin).
- Only then is the dermoscope used.
- At this stage, all the information is considered together, and a holistic management decision made.
- The fifth aspect cannot be over-emphasised: know your limitations, and if there is any doubt, refer for a specialist opinion.