Enhanced Skin Self-examination: A Novel Approach to Skin Cancer Monitoring and Follow-up

Advances in mobile telephone technology and available dermoscopic attachments for mobile telephones have created a unique opportunity for consumer-initiated mobile teledermoscopy. At least 2 companies market a dermoscope attachment for an iPhone (Apple), forming a mobile teledermoscope. These devices and the corresponding software applications (apps) enable (1) lesion magnification (at least ×20) and visualization with polarized light; (2) photographic documentation using the telephone camera; (3) lesion measurement (ruler); (4) adding of image and lesion details; and (5) e-mail data to a teledermatologist for review. For lesion assessment, the asymmetry-color (AC) rule has 94% sensitivity and 62% specificity for melanoma identification by consumers.¹ Thus, consumers can be educated to recognize asymmetry and color patterns in suspect lesions. However, we know little about consumers' use of mobile teledermoscopy for lesion assessment.

Our objective was to assess the feasibility of consumer mobile teledermoscopy to potentially complement skin self-examination (SSE). We documented satisfaction with SSE and AC rule education, mobile teledermoscopy, and mobile teledermoscopy outcomes (number of e-mailed lesions per participant, image quality, lesion diversity, and lesion location). We recorded the likelihood of malignancy and need for further follow-up (excision, biopsy) after telediagnosis.

Ethical clearance was granted by the Human Research Ethics Committee at Queensland University of Technology (QUT 1100001392) and Metro South Health Service District from the Princess Alexandra Hospital (PAH) (PAH HREC/09/QPAH/126/AM02). This study was part of the larger PAH Nevi Surveillance Study (NSS). The convenience sample consisted of 10 NSS participants, 18 years or older (4 women, 6 men), with a personal or family history of melanoma, atypical nevi, or multiple moles. Experience with a smartphone was not necessary. The study was conducted from November 2011 to May 2012.

Participants completed a survey on sociodemographic characteristics, risk factors, and SSE practice and then received the following materials to use for home SSEs: (1) a booklet explaining the AC rule and SSE instructions and a body chart to record lesion locations; (2) the mobile teledermoscope comprising an iPhone 3 (app preloaded) attached to a Handyscope (FotoFinder Systems); and (3) additional image information and instructions for photographing and e-mailing the photographs to researchers.

Guided by the AC rule, participants photographed lesions found during SSE. The teledermatologist (H.P.S.) reviewed the images for quality and telediagnosis. Participants had 1 week to complete the SSE and photograph submission, and all used the same mobile teledermoscope. They mailed the body chart along with a follow-up survey on satisfaction with mobile teledermoscopy and its usefulness for SSE.

Participant characteristics and feasibility findings are listed in Table 1. Participants submitted 66 photographs (mean, 6.6 photographs per participant; range, 2-12 photographs). Most photographs were of good quality (88%), allowing the following telediagnoses: 33 dysplastic nevi (50%); 18 benign nevi (27%); 5 seborrheic keratoses (8%); 1 solar lentigo (2%); and 1 angioma (2%). Lesion types and locations are illustrated in Figure 1, example lesions in Figure 2. Most lesions were rated as having a low likelihood of malignancy, not needing excision (Table 2).

Routine SSE potentially improves melanoma early detection; however, SSE sensitivity is low (25%-93%), and specificity is higher (83%-97%).² Only recently has patient-performed dermoscopy been proposed to complement SSE. Goulart et al³ reported 2 cases of consumers who independently purchased conventional dermoscopes and, without training, detected a melanoma and a dysplastic nevus. Now that smartphones are becoming ubiquitous, the commercial availability of dermoscopy attachments likewise may increase consumer-initiated mobile teledermoscopy. Some researchers have noted that sensitivity may decrease among untrained physicians using dermoscopes compared to evaluation using the naked eye,⁴ but most studies have reported better sensitivity and specificity using dermoscopes than using the naked eye.⁵ It will be important to carefully assess similar outcomes for consumers. Consumers might improve their sensitivity, but they might also misjudge a dangerous lesion as unremarkable or—probably the greater concern—overlook lesions completely (eg, those on hard-to-see areas).

We demonstrated that providing melanoma high-risk consumers with brief dermoscopy instructions and a mobile teledermoscope to examine skin lesions detected during SSE is feasible. Participants had few issues with the mobile teledermoscopy procedures. They were able to select atypical moles for photographs; yet they also selected benign nevi, indicating the need for more training about benign nevi³ or optimization of the technology.

Advantages of mobile teledermoscopy are convenience (scheduling, travel) and rapid telediagnosis from the teledermatologist.⁶ Disadvantages are availability of dermoscope attachments (currently for smartphones only), and cost, both of which may limit consumer use. Other barriers for consumers may include access to technology and a teledermatologist,⁷ low health literacy precluding self-education, and concern about identification of most worrisome lesions. For dermatologists, preference for detailed medical history taking and tactile assessment of lesions, time, funding and medical-legal risk may represent barriers. Still, for high-risk consumers, mobile teledermoscopy may be a useful SSE tool, meriting further study. This study represents the first phase of our consumer mobile teledermoscopy research program.

Correspondence: Dr Janda, School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD 4061, Australia (m.janda@qut.edu.au).

Accepted for Publication: September 6, 2012.

Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Janda, Loescher, and Soyer. Acquisition of data: Janda. Analysis and interpretation of data: Janda, Loescher, and Soyer. Drafting of the manuscript: Janda and Loescher. Critical revision of the manuscript for important intellectual content: Janda, Loescher, and Soyer. Statistical analysis: Janda. Obtained funding: Janda. Administrative, technical, and material support: Janda and Loescher. Study supervision: Janda and Soyer.

Funding/Support: This study was supported in part by National Health and Medical Research Council of Australia (NHMRC) Practitioner Fellowship APP1020145 (Dr Soyer), NHMRC grant CDA 553034 (Dr Janda), and the Queensland University of Technology Institute of Health and Biomedical Innovation.

Role of the Sponsors: The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Additional Contributions: We thank the Pan-Pacific Skin Cancer Consortium for providing the foundation for our research team.