Total Body Skin Examination Practices: A Survey Study Amongst Dermatologists at High-Risk Skin Cancer Clinics

Abstract

Background/Objectives: Although total body skin examination (TBSE) is the primary screening mechanism for melanoma, there is no consensus on which anatomic sites a screening TBSE should include. We sought to establish which anatomic sites are examined during routine (>90%) TBSEs of patients at high risk for skin cancer.
 Methods: A Google survey was emailed to 173 international dermatologist skin cancer specialists.
 Results: More than 75% of participants reported routinely examining the scalp, ears, face and neck, trunk, breasts, inframammary areas, axillae, extremities, palms and soles, nails, interdigital spaces, and buttocks. The least frequently inspected anatomic sites included genitalia, with male genitalia more frequently examined than female (penis n = 39; 52%; labia majora n = 21; 28%; P = 0.003), the perianal region (n = 26; 34.7%), and the ocular conjunctiva and oral mucosa (n = 35; 46.7%). Participants cited not screening these areas because of perceived patient discomfort, low prevalence of malignancy, and the expectation that other specialists examine the area.
 Conclusions: The role of routine surveillance of neglected anatomic sites is unclear and warrants further discussion weighing potential mortality benefit against the incidence of melanoma in obscure sites, morbidity of intervention in sensitive sites, cost-effectiveness, and potential for patient discomfort.

The role of technology in melanoma screening and diagnosis

“…The simplest method to screen for melanoma is the unaided total body skin examination, which can be performed by physicians and patients alike, for example, using the “ABCDE” rule (asymmetry, border irregularity, non‐uniform color, diameter greater than 6 mm, and evolving over time) (Soltani‐Arabshahi et al., 2015) or the “ugly duckling” rule (lesion dissimilar to other lesions). However, while guidelines for what constitutes a TBSE have been recommended by an expert panel (Johnson et al., 2017), examination of genitals and other anatomic sites is commonly omitted in “routine TBSE” (Bajaj et al., 2019).…”

Identification of Incidental Skin Cancers Among Adults Referred to Dermatologists for Suspicious Skin Lesions

“…Total body skin examination (TBSE) is the systematic examination of a patient’s entire skin surface, nails, hair, and relevant mucosal surfaces aiming to identify incidental skin cancers that the patient may not be able to see, leading to earlier cancer detection. 11 , 12 , 13 Screening of the general population using TBSE remains controversial, 14 with ambiguity about which sites should be included in TBSE 15 and concerns about cost-effectiveness. 16 In 1 UK study, as many as a third of melanomas were incidental lesions detected by TBSE, 11 with higher proportions reported in other countries where UV exposure may be greater.…”

The Genital Examination in Dermatologic Practice

“…Additionally, female genitalia were examined less frequently than male genitalia (labia majora, 28%; penis, 52%; P=.003). 5 Another survey of US academic dermatologists (23 dermatologists, 1 nurse practitioner) found that only 4% always visually inspected the vulva during routine annual examinations, and 50% did not think that vulvar examination was the dermatologist's responsibility. 6 Similar findings were reported in a survey of US dermatology residents.…”

“…Based on the surveys of dermatologists and dermatology residents, the most common reason cited for not examining these sites was patient discomfort, but there also was a dominant belief that other specialties, such as gynecologists, urologists, or primary care providers, routinely examine these areas. 5,7 Time constraints also were a concern.…”