Dermoscopy Training Course Improves Ophthalmologists' Accuracy in Diagnosing Atypical Pigmented Periorbital Skin Lesions

Abstract

Background/objectives: Facial pigmented skin lesions are extremely common, starting from the fourth to fifth decades, especially in South-European countries, often located in the periorbital region. These include malignant forms, Lentigo maligna (LM) and lentigo maligna melanoma (LMM), characterized by growing incidence, and a series of benign simulators, including solar lentigo (SL), pigmented actinic keratosis (PAK), seborrheic keratosis (SK) and lichen planus-like keratosis (LPK). The clinical differential diagnosis of atypical pigmented skin lesions (aPFLs) can be difficult, even for dermatologists, leading to inappropriate skin biopsies with consequent aesthetic impacts. Dermoscopy of the facial area is a specific dermoscopic field that requires dedicated training and proved to increase diagnostic accuracy in dermatologists. Since these lesions are often seen by ophthalmologists at first, we aimed to evaluate the effect of a focused dermoscopy training course on a group of ophthalmologists naïve to the use of a dermatoscope.

Methods: A set of 80 periorbital pigmented skin lesions with both clinical and dermoscopic images was selected and evaluated by six ophthalmologists before and after a one-day intensive dermoscopic training course. They were required to evaluate 80 periorbital lesions one month before and after a one-day intensive dermoscopic training course, illustrating second-level diagnostic options such as reflectance confocal microscopy (RCM), obtaining a total of 480 evaluations. Specifically, they had to provide, for each case, a punctual diagnosis and a management option among dermoscopic follow-up/skin biopsy/RCM/LC-OCT. Descriptive statistics were carried out, and the accuracy (ACC), sensitivity (SE), and specificity (SP), with their 95% confidence interval (95% CI), were estimated.

Results: In the pre-course test, ophthalmologists achieved 84.0% SP, 33.3% SE and 63.7% ACC, while after the course, SE increased by +9% (i.e., 41.7%), SP decreased by 4%, and ACC remained comparable, i.e., 64.6%. In the management study, the percentage of benign lesions for which a close dermoscopic follow-up was suggested significantly decreased (51.6% versus 22.2%), in parallel with an increase in the number of lesions referred for RCM. As for malignant cases, the reduction in responses "close dermoscopic follow-up" decreased from 37.0% to 9.9%, (-27%), in favor of RCM (+15%) and skin biopsy (+12%).

Conclusions: The ophthalmologists proved to be very receptive in quickly metabolizing and putting into practice the concepts learned during the one-day intensive dermoscopy training course. Indeed, after only a one-day lesson, they were able to increase their SE by 9% and to improve their management strategy. The present findings highlight the importance of providing training ophthalmologists in dermoscopy during residency programs, in terms of benefits for the correct patient care.

Keywords: dermoscopy; eyelid skin lesions; lentigo maligna; ophthalmology; pigmented periorbital lesions.

Figure 1

Example of different atypical pigmented facial lesions (aPFL) of the periorbital region with similar clinical appearance: macroscopic clinical images (a,c,e,g,i) and corresponding dermoscopic images (b,d,f,h,j) taken with polarized dermoscopy, OM 20X. Three aPFL lesions appearing as brownish macule and similar dimensions: a pigmented actinic keratosis in a 50-year-old male, with 12 mm maximum diameter (a), showing an homogenous reticular pattern sparing the follicular openings (b); a solar lentigo in a 71-year-old woman, with 7 mm maximum diameter, showing yellowish-brownish homogenous pigmentation around the hair follicoles (d); a lentigo maligna in a 66-year-old male, with 9 mm maximum diameter, showing granular brownish-grey pattern and polygonal structures involving follicular openings (f). A 12 mm seborrheic keratosis combined with a solar lentigo in a 59-year-old woman (g) showing cerebriform pattern and comedo-like openings in the inferior part (h). An 8 mm lentigo maligna melanoma in an 87-year-old male (i) showing asymmetry of structures and colors, granular pattern, blue-grey areas and evident involvement of the follicular openings (j).

Figure 1

Example of different atypical pigmented facial lesions (aPFL) of the periorbital region with similar clinical appearance: macroscopic clinical images (a,c,e,g,i) and corresponding dermoscopic images (b,d,f,h,j) taken with polarized dermoscopy, OM 20X. Three aPFL lesions appearing as brownish macule and similar dimensions: a pigmented actinic keratosis in a 50-year-old male, with 12 mm maximum diameter (a), showing an homogenous reticular pattern sparing the follicular openings (b); a solar lentigo in a 71-year-old woman, with 7 mm maximum diameter, showing yellowish-brownish homogenous pigmentation around the hair follicoles (d); a lentigo maligna in a 66-year-old male, with 9 mm maximum diameter, showing granular brownish-grey pattern and polygonal structures involving follicular openings (f). A 12 mm seborrheic keratosis combined with a solar lentigo in a 59-year-old woman (g) showing cerebriform pattern and comedo-like openings in the inferior part (h). An 8 mm lentigo maligna melanoma in an 87-year-old male (i) showing asymmetry of structures and colors, granular pattern, blue-grey areas and evident involvement of the follicular openings (j).

Figure 2

Accuracy of ophthalmologists’ diagnoses before and after the course.

Figure 3

Ophthalmologists suggested management of periorbital pigmented skin lesions before and after the course.