The Role of Teledermatology and Teledermoscopy in the Diagnosis of Actinic Keratosis and Field Cancerization

Published:March 03, 2020DOI:https://doi.org/10.1016/j.jid.2020.02.013
      Actinic keratosis (AK) and field cancerization are increasing health problems insufficiently diagnosed by primary care physicians. The objective of this study was to assess the validity and reliability of teledermatology (TD) and teledermoscopy in the diagnosis of AK and field cancerization in a gatekeeper healthcare model. A prospective diagnostic test evaluation was done to assess the diagnostic concordance, accuracy, and performance parameters and the interobserver and intraobserver concordances of TD and teledermoscopy compared with dermatologists’ face-to-face evaluation or histopathology. A total of 636 patients with 1,000 keratotic skin lesions were included. TD diagnostic concordance for AK and field cancerization evaluation was very high and superior to primary care physicians’ diagnosis (92.4% vs. 62.4% and 96.7% vs. 51.8%, P < 0.001). TD sensitivity, specificity, and positive and negative predictive values for AK diagnosis and field cancerization were high (range = 82.2–95.0) and better than primary care physicians’ diagnosis. Teledermoscopy yielded better results in diagnostic concordance, performance parameters, and AK subtypes. Intraobserver and interobserver agreement was >0.83. TD and, to a greater extent, teledermoscopy may be valid and reliable tools for the diagnosis of AK and field cancerization and may improve diagnosis and correct allocation and management in gatekeeper healthcare systems. It can be an alternative tool to training primary care physicians in direct diagnosis of these lesions.

      Abbreviations:

      AK ( Actinic keratosis), FTF ( face-to-face), PCP ( primary care physician), PSL ( pigmented skin lesions), SCC ( squamous cell carcinoma), TD ( teledermatology), TDS ( teledermoscopy)
      To read this article in full you will need to make a payment

      References

        • Ackerman A.B.
        • Mones J.M.
        Solar (actinic) keratosis is squamous cell carcinoma.
        Br J Dermatol. 2006; 155: 9-22
        • Braakhuis B.J.
        • Tabor M.P.
        • Kummer J.A.
        • Leemans C.R.
        • Brakenhoff R.H.
        A genetic explanation of Slaughter’s concept of field cancerization: evidence and clinical implications.
        Cancer Res. 2003; 63: 1727-1730
        • Bruce A.F.
        • Mallow J.A.
        • Theeke L.A.
        The use of teledermoscopy in the accurate identification of cancerous skin lesions in the adult population: a systematic review.
        J Telemed Telecare. 2018; 24: 75-83
        • Castillo-Arenas E.
        • Garrido V.
        • Serrano-Ortega S.
        Skin conditions in primary care: an analysis of referral demand.
        Actas Dermosifiliogr. 2014; 105: 271-275
        • Fernández-Figueras M.T.
        • Carrato C.
        • Sáenz X.
        • Puig L.
        • Musulen E.
        • Ferrándiz C.
        • et al.
        Actinic keratosis with atypical basal cells (AK I) is the most common lesion associated with invasive squamous cell carcinoma of the skin.
        J Eur Acad Dermatol Venereol. 2015; 29: 991-997
        • Ferrándiz L.
        • Ojeda-Vila T.
        • Corrales A.
        • Martín-Gutiérrez F.J.
        • Ruíz-de-Casas A.
        • Galdeano R.
        • et al.
        Internet-based skin cancer screening using clinical images alone or in conjunction with dermoscopic images: a randomized teledermoscopy trial.
        J Am Acad Dermatol. 2017; 76: 676-682
        • Figueras Nart I.
        • Cerio R.
        • Dirschka T.
        • Dréno B.
        • Lear J.T.
        • Pellacani G.
        • et al.
        Defining the actinic keratosis field: a literature review and discussion.
        J Eur Acad Dermatol Venereol. 2018; 32: 544-563
        • Finnane A.
        • Dallest K.
        • Janda M.
        • Soyer H.P.
        Teledermatology for the diagnosis and management of skin cancer: a systematic review.
        JAMA Dermatol. 2017; 153: 319-327
        • Flohil S.C.
        • van der Leest R.J.
        • Dowlatshahi E.A.
        • Hofman A.
        • de Vries E.
        • Nijsten T.
        Prevalence of actinic keratosis and its risk factors in the general population: the Rotterdam study.
        J Invest Dermatol. 2013; 133: 1971-1978
        • Higashi M.K.
        • Veenstra D.L.
        • Langley P.C.
        Health economic evaluation of non-melanoma skin cancer and actinic keratosis.
        Pharmacoeconomics. 2004; 22: 83-94
        • Holme S.A.
        • Scott-Lang V.E.
        • Ooi E.T.
        • Matthews A.G.
        • Darling M.I.
        • Needham D.
        • et al.
        The south-east Scotland dermatology workload study: 30 years’ analysis.
        Br J Dermatol. 2012; 167: 123-130
        • Hsiao J.L.
        • Oh D.H.
        The impact of store-and-forward teledermatology on skin cancer diagnosis and treatment.
        J Am Acad Dermatol. 2008; 59: 260-267
        • Huerta-Brogeras M.
        • Olmos O.
        • Borbujo J.
        • Hernández-Núñez A.
        • Castaño E.
        • Romero-Maté A.
        • et al.
        Validation of dermoscopy as a real-time noninvasive diagnostic imaging technique for actinic keratosis.
        Arch Dermatol. 2012; 148: 1159-1164
        • Janda M.
        Teledermatology: its use in the detection and management of actinic keratosis.
        Curr Probl Dermatol. 2015; 46: 101-107
        • Kittler H.
        • Pehamberger H.
        • Wolff K.
        • Binder M.
        Diagnostic accuracy of dermoscopy.
        Lancet Oncol. 2002; 3: 159-165
        • Lallas A.
        • Argenziano G.
        • Moscarella E.
        • Longo C.
        • Simonetti V.
        • Zalaudek I.
        Diagnosis and management of facial pigmented macules.
        Clin Dermatol. 2014; 32: 94-100
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Lee J.J.
        • English 3rd, J.C.
        Teledermatology: a review and update.
        Am J Clin Dermatol. 2018; 19: 253-260
        • Lowell B.A.
        • Froelich C.W.
        • Federman D.G.
        • Kirsner R.S.
        Dermatology in primary care: prevalence and patient disposition.
        J Am Acad Dermatol. 2001; 45: 250-255
        • Lim D.
        • Oakley A.M.
        • Rademaker M.
        Better, sooner, more convenient: a successful teledermoscopy service.
        Australas J Dermatol. 2012; 53: 22-25
        • Madan V.
        • Lear J.T.
        • Szeimies R.M.
        Non-melanoma skin cancer.
        Lancet. 2010; 375: 673-685
        • Massone C.
        • Cerroni L.
        The many clinico-pathologic faces of actinic keratosis: an atlas.
        Curr Probl Dermatol. 2015; 46: 64-69
        • Micantonio T.
        • Neri L.
        • Longo C.
        • Grassi S.
        • Di Stefani A.
        • Antonini A.
        • et al.
        A new dermoscopic algorithm for the differential diagnosis of facial lentigo maligna and pigmented actinic keratosis.
        Eur J Dermatol. 2018; 28: 162-168
        • Moreno-Ramírez D.
        • Ferrándiz L.
        A 10-year history of teledermatology for skin cancer management.
        JAMA Dermatol. 2015; 151: 1289-1290
        • Moreno-Ramirez D.
        • Ferrandiz L.
        • Galdeano R.
        • Camacho F.M.
        Teledermatoscopy as a triage system for pigmented lesions: a pilot study.
        Clin Exp Dermatol. 2006; 31: 13-18
        • Moreno-Ramirez D.
        • Ferrandiz L.
        • Nieto-Garcia A.
        • Carrasco R.
        • Moreno-Alvarez P.
        • Galdeano R.
        • et al.
        Store-and-forward teledermatology in skin cancer triage: experience and evaluation of 2009 teleconsultations.
        Arch Dermatol. 2007; 143: 479-484
        • Moreno-Ramírez D.
        • Raya-Maldonado J.
        • Morales-Conde M.
        • Ojeda-Vila T.
        • Martín-Gutiérrez F.J.
        • Ruíz-de-Casas A.
        • et al.
        Increasing frequency of seborrheic keratosis diagnoses as a favorable consequence of teledermatology-based skin cancer screening: a cross-sectional study of 34,553 patients.
        Am J Clin Dermatol. 2017; 18: 681-685
      1. Muñoz-Santos C, Sola-Ortigosa J, Guilabert A, Navinés A, Llargués E, Botta M, et al. Teledermoscopy for skin tumors screening- experience in a regional hospital in Catalonia. Paper presented at: 5th World Congress Teledermatology, 18–20 September 2014a; Barcelona, Spain.

      2. Muñoz-Santos C, Sola-Ortigosa J, Robies M, Segui N, Echevarria V, Guilabert A, et al. Teledermatology and teledermatoscopy. Experience in a regional general hospital with a high waiting list and reference population. Paper presented at: 42 Congreso Nacional de Dermatología y Venereología. 4-7 June 2014b. Gran Canaria, Spain [in Spanish].

        • Naka F.
        • Lu J.
        • Porto A.
        • Villagra J.
        • Wu Z.H.
        • Anderson D.
        Impact of dermatology eConsults on access to care and skin cancer screening in underserved populations: a model for teledermatology services in community health centers.
        J Am Acad Dermatol. 2018; 78: 293-302
        • Noels E.C.
        • Lugtenberg M.
        • van Egmond S.
        • Droger S.M.
        • Buis P.A.J.
        • Nijsten T.
        • et al.
        Insight into the management of actinic keratosis: a qualitative interview study among general practitioners and dermatologists.
        Br J Dermatol. 2019; 181: 96-104
        • Olsen E.A.
        • Abernethy M.L.
        • Kulp-Shorten C.
        • Callen J.P.
        • Glazer S.D.
        • Huntley A.
        • et al.
        A double-blind, vehicle-controlled study evaluating masoprocol cream in the treatment of actinic keratoses on the head and neck.
        J Am Acad Dermatol. 1991; 24: 738-743
        • Piccolo D.
        • Smolle J.
        • Wolf I.H.
        • Peris K.
        • Hofmann-Wellenhof R.
        • Dell’Eva G.
        • et al.
        Face-to-face diagnosis vs telediagnosis of pigmented skin tumors: a teledermoscopic study.
        Arch Dermatol. 1999; 135: 1467-1471
        • Romero G.
        • Sánchez P.
        • García M.
        • Cortina P.
        • Vera E.
        • Garrido J.A.
        Randomized controlled trial comparing store-and-forward teledermatology alone and in combination with web-camera videoconferencing.
        Clin Exp Dermatol. 2010; 35: 311-317
        • Rosen T.
        • Lebwohl M.G.
        Prevalence and awareness of actinic keratosis: barriers and opportunities.
        J Am Acad Dermatol. 2013; 68: S2-S9
        • Röwert-Huber J.
        • Patel M.J.
        • Forschner T.
        • Ulrich C.
        • Eberle J.
        • Kerl H.
        • et al.
        Actinic keratosis is an early in situ squamous cell carcinoma: a proposal for reclassification.
        Br J Dermatol. 2007; 156: S8-S12
        • Salasche S.J.
        Epidemiology of actinic keratoses and squamous cell carcinoma.
        J Am Acad Dermatol. 2000; 42: 4-7
        • Şenel E.
        • Baba M.
        • Durdu M.
        The contribution of teledermatoscopy to the diagnosis and management of non-melanocytic skin tumours.
        J Telemed Telecare. 2013; 19: 60-63
        • Sinz C.
        • Tschandl P.
        • Rosendahl C.
        • Akay B.N.
        • Argenziano G.
        • Blum A.
        • et al.
        Accuracy of dermatoscopy for the diagnosis of nonpigmented cancers of the skin.
        J Am Acad Dermatol. 2017; 77: 1100-1109
        • Tan E.
        • Oakley A.
        • Soyer H.P.
        • Haskett M.
        • Marghoob A.
        • Jameson M.
        • et al.
        Interobserver variability of teledermoscopy: an international study.
        Br J Dermatol. 2010; 163: 1276-1281
        • Trettel A.
        • Eissing L.
        • Augustin M.
        Telemedicine in dermatology: findings and experiences worldwide - a systematic literature review.
        J Eur Acad Dermatol Venereol. 2018; 32: 215-224
        • van der Heijden J.P.
        • Thijssing L.
        • Witkamp L.
        • Spuls P.I.
        • de Keizer N.F.
        Accuracy and reliability of teledermatoscopy with images taken by general practitioners during everyday practice.
        J Telemed Telecare. 2013; 19: 320-325
        • Warshaw E.M.
        • Gravely A.A.
        • Nelson D.B.
        Reliability of store and forward teledermatology for kin neoplasms.
        J Am Acad Dermatol. 2015; 72: 426-435
        • Warshaw E.M.
        • Hillman Y.J.
        • Greer N.L.
        • Hagel E.M.
        • MacDonald R.
        • Rutks I.R.
        • et al.
        Teledermatology for diagnosis and management of skin conditions: a systematic review.
        J Am Acad Dermatol. 2011; 64: 759-772
        • Warshaw E.M.
        • Lederle F.A.
        • Grill J.P.
        • Gravely A.A.
        • Bangerter A.K.
        • Fortier L.A.
        • et al.
        Accuracy of teledermatology for nonpigmented neoplasms.
        J Am Acad Dermatol. 2009; 60: 579-588
        • Warshaw E.M.
        • Lederle F.A.
        • Grill J.P.
        • Gravely A.A.
        • Bangerter A.K.
        • Fortier L.A.
        • et al.
        Accuracy of teledermatology for pigmented neoplasms.
        J Am Acad Dermatol. 2009; 61: 753-765
        • Whited J.D.
        • Hall R.P.
        • Simel D.L.
        • Horner R.D.
        Primary care clinicians’ performance for detecting actinic keratoses and skin cancer.
        Arch Intern Med. 1997; 157: 985-990
        • Whited J.D.
        • Horner R.D.
        • Hall R.P.
        • Simel D.L.
        The influence of history on interobserver agreement for diagnosing actinic keratoses and malignant skin lesions.
        J Am Acad Dermatol. 1995; 33: 603-607
        • Zalaudek I.
        • Piana S.
        • Moscarella E.
        • Longo C.
        • Zendri E.
        • Castagnetti F.
        • et al.
        Morphologic grading and treatment of facial actinic keratosis.
        Clin Dermatol. 2014; 32: 80-87