Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 1 Dermoscopy Use in Africa: Determinants and Challenges Enechukwu Nkechi Anne 1, Adebola O Ogunbiyi2, Awatef Kelati3, Ahmed Sadek4, Ibrahima Traoré5, Daudi Mavura6-7 1 Nnamdi Azikiwe University/Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria 2 Department of Medicine, College of Medicine, University of Ibadan, Nigeria 3 Dermatology Department, University Hospital Cheikh Khalifa and the University Hospital Mohammed VI. Faculty of Medicine, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco 4 Cairo Hospital for Dermatology & Venereology (Al-Haud Al-Marsoud), Cairo, Egypt 5 Gamal Abdel Nasser University, La Source University, Conakry, Guinea 6 Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania 7 Regional Dermatology Training Centre (RDTC), Kilimanjaro Christian Medical Centre (KCMC) Hospital, Moshi, Tanzania Key words: Dermoscopy, uses, dark skin, challenges Citation: Enechukwu NA, Ogunbiyi AO, Kelati A, Sadek A, Traoré I, Mavura D. Dermoscopy Use in Africa: Determinants and Challenges. Dermatol Pract Concept. 2024;14(2):e2024098. DOI: https://doi.org/10.5826/dpc.1402a98 Accepted: December 20, 2023; Published: April 2024 Copyright: ©2024 Enechukwu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Dr. Enechukwu Nkechi Anne, Senior Lecturer/ Honorary Consultant Dermatologist and Venereologist, Nnamdi Azikiwe University/ Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria. E-mail: na.enechukwu@unizik.edu.ng Introduction: Dermoscopy has evolved over the years beyond distinguishing benign pigmented lesions from melanoma to diagnosing virtually all diseases in dermatology. Overwhelming evidence demonstrates its utility in improving diagnostic accuracy, reducing unnecessary biopsies and lesion monitoring. Dermoscopy is widely used in Western nations, hence most descriptions of lesions in liter- ature are predominantly on Fitzpatrick skin types I-III. Current evidence shows that there are unique dermoscopic features in the dark skin as a result of pigment and pathological reactions. Nationwide surveys and reports have been conducted across several continents to highlight prevalence and factors influencing dermoscopy use with the hope of maximizing its apparent benefits. There are currently no such reports from Africa. Objectives: To evaluate dermoscopy use and its determinants among dermatologists in Africa. Methods: A cross-sectional study. Online forms were e-mailed to individual practicing dermatologists and members of the African Society of Dermatologists and Venereologists. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 Introduction There has been a rising global recognition of the utility of dermoscopy for diagnosis and management of skin diseases beyond neoplastic lesions in all skin types [1-5]. In addition to improving diagnostic accuracy of skin lesions thereby fa- cilitating triage of skin lesions in primary care dermatology while reducing unnecessary biopsies, it also improves preci- sion in determining the margins of excision and monitoring of lesions during treatment [6-8]. Dermoscopy is widely used in Western nations, hence most dermoscopic description of skin lesions in literature are predominantly in Fitzpatrick skin types I-III [9-14]. Current evidence shows that certain dermoscopic fea- tures may be specific to skin of color as a result of the role of pigment and reactionary effects due to inflammation [15, 16]. Additionally, several skin diseases are exclusively seen or commoner in the darker skin types. There are sev- eral dermoscopic descriptions of a wide variety of skin dis- eases in the fairer skin which has been streamlined by the standardization of terminologies for diagnostic criteria for specific dermatoses [7, 17-19]. There are however relatively few studies on dermoscopic features of skin lesions in the darker skin phenotypes [15,16, 20]. Until recently, there has not been standardized terminologies for the dermoscopy of skin lesions in skin of color [21,22]. However, in order to demonstrate the diagnostic utility of dermoscopy and for- mulate useful diagnostic criteria in darker skin types, many more studies from this population are needed. The degree of usefulness of dermoscopy and the precision of dermoscopic criteria is dependent on appropriate use which in turn depends on proper training, use of standardized guide- lines and appropriate reporting [9]. There are several articles on the use of dermoscopy among dermatologists in Europe, Aus- tralia, U.K, USA and Saudi Arabia [5,9-11,23-31]. There are currently no reports on dermoscopy use in Africa although a greater majority of persons with darker skin phenotypes live in Africa. This survey was carried out to evaluate the use of dermoscopy among practicing dermatologists in Africa, determine factors that predict its use and the drawbacks (if any) to the use of dermoscopy in Africa. It will serve as a valuable groundwork for postulating why there are few re- ports from Africa and the findings can be used as a frame- work to enhance the use of dermoscopy in Africa. Objectives To evaluate the frequency of use of dermoscopy among African Dermatologists in their daily practice and to identify the determining factors, attitudes to use and also to high- light the obstacles to the use of dermoscopy among African dermatologists. Methods This was a cross sectional online survey conducted in Africa. Online forms were sent in person and through emails and/ or WhatsApp posts to dermatologists practicing in Africa and members of the African Society of Dermatologists and Venereologists over a 3-month period. Study Participants Participants were recruited from the African society of Der- matologists and Venereologists (ASDV) and Dermatologic so- cieties in Africa. Members were emailed through the ASDV and the Nigerian Association of Dermatologists (NAD) mail- ing list and WhatsApp group page. Snowballing method was also used to share the link to the online survey (through col- league dermatologists) with other dermatologists practicing in Africa in their contact list. Respondents comprised specialist dermatologists (consultants) and dermatology residents. Pub- lic health practitioners and pediatricians who were affiliates of ASDV and NAD and also provide dermatologic care also participated. Reminders were sent fortnightly throughout the study period. Approval for the study was obtained from the Anambra State Ministry of Health Ethics Committee, Awka and informed consent was obtained from all study participants. Study Instrument The online questionnaire was semi structured and designed using guidelines in the technique and use of dermoscopy Results: There were 196 respondents from 24 African countries. Half of them used dermoscopy. Training, practice settings and location, provision of dermatoscopes by institutions and knowledge of criteria were notable significant determinants. Multiple training exposures, knowledge of criteria, availability of dermatoscopes, use of both hand-held and videodermatoscopes, average number of patients seen per day, and a positive outlook towards dermoscopy were significant determinants of fre- quency of use. Leading impediments were lack of training and inadequate dermatoscopes in practice. Conclusions: Dermoscopy use in Africa is relatively low. Incorporating dermoscopy training into the curriculum with provision of dermatoscopes by training institutions will promote wider usage. Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 3 combined with other questions adapted from previous sur- veys on dermoscopy use [9,18, 19]. It had 31 multiple choice questions bordering on demographics, practice settings, der- moscopy training, availability of dermatoscopes, frequency of use, knowledge of indications for use, perceived diagnos- tic usefulness in skin of color; knowledge and use of tech- niques and dermoscopic criteria. It was originally designed in English language and was also translated to French. Data Analysis Data cleaning was done using Microsoft office Excel, ver- sion 2016 (Microsoft Corporation). Inadequate responses were removed from the data set. At the point of question on training, those without training were not allowed proceed with the rest of the survey, instead, they were directed to tell why they did not have training before submitting. All the re- spondents were classified as either user or non-users of der- moscopy. Users of dermoscopy were further classified into high frequency users (uses dermoscopy at least two times a week) and low frequency users (uses dermoscopy less than two times a week). Continuous variables (age, duration of practice and duration of training in dermoscopy) were sum- marized as mean and standard deviation; and then grouped into non-continuous variables. Non-continuous variables were summarized as frequency and percentages. Chi-square test for association (when expected cell count =>5) or Fish- ers exact test (when expected cell count <5) were used to check for associations between use of dermoscopy and so- ciodemographic and work variables; similarly, association between frequency of use and sociodemographic and work settings related variables were sought. Further analysis of in- terplay between the factors that influence use and frequency of use of dermoscopy was done using multinomial logistic regression statistics, employing the stepwise forward entry method. Predictors are given as adjusted odds ratios (AOR) with 95% confidence intervals (CI). In order to avoid over exaggerated odd ratios, categories of variables that were very few were removed from the models. A first model with several possible predictors was made; then, only the signifi- cant predictors from the first model were moved to a second model. All statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 25 (IBM Corp.). For all inferential statistical methods, the threshold for sta- tistical significance was predetermined at a significance level of p < 0.05. Results Socio-demographics A total of 196 respondents (155 dermatology special- ists, 29 senior residents, 11 junior residents and 1 intern) from 24 countries completed the survey with a response rate (proportion of respondents from the total number of dermatologists contacted through successfully delivered emails/posts) of 31.8% (Figure 1). A majority (72.4%) of the respondents were females with most practicing in pub- lic or government funded teaching Hospitals and in urban localities. Determinants of Dermoscopy Use Among African Dermatologists Half (50%) of the respondents used dermoscopy in their practice. The factors influencing the use of dermoscopy in practice settings included training in dermoscopy, country of practice, provision of dermatoscopes by training insti- tutions and knowledge of dermoscopic criteria/guidelines for the diagnosis of skin diseases (Tables 1 and 2). Nota- bly, only 32% of the respondent training centres provided dermatoscopes. On multivariate analysis, practice settings and source of information about dermoscopy were significant predictors of use of dermoscopy. Public/government funded teaching hospitals (affiliated with universities) were more likely to use dermoscopy than public/government funded Federal Medi- cal Centers (not affiliated with universities) with an odd ra- tio of 2.58 (P = 0.02). Those that heard about dermoscopy during residency training were more likely to use dermoscopy than those that heard it from conferences (odd ratio = 3.03 and P = 0.01); and from colleagues (odd ratio = 3.93 and P = 0.03). Put in a second model, practice setting was the only significant predictor with those in public/government funded teaching hospitals more likely to use dermoscopy than public/government funded federal medical centers, (odd ratio= 2.49; P = 0.02). Frequency of Use of Dermoscopy More than half (66.3%) of the individuals who used der- moscopes were high frequency users (defined as using der- moscopy 2-3 times per week or every working day) while 33.7% were low frequency users (once in one or two weeks or rarely-less than once in two weeks). Provision of dermato- scopes by training centres (P = 0.02), average number of pa- tients seen per day (P = 0.002), use of existing dermoscopic criteria to aid diagnosis of skin diseases (P = 0.009), a posi- tive outlook towards dermoscopy with respect to dermatol- ogy practice (P = 0.007) and use of both hand-held and video dermatoscopes were significant determinants of frequency of use (Table 3). On multivariate analysis, practice settings, current cadre, average number of patients seen daily, and number of train- ing sessions were significant determinants of frequency of dermoscopy use. Those in Private Hospitals were less likely to be low frequency users than public/government funded teaching hospitals (odd ratio = 0.03, P = 0.02); Registrars/ 4 Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 Figure 1: (A) Distribution of respondents by country of practice. (B) Distribution of users by country (percentage users) residents were less likely to be low frequency users than specialists/consultants (odd ratio = 0.08, P = 0.05). Also, those that see <10 patients daily were more likely to be low frequency users than those seeing 21-50 patients (odd ratio = 41.53, P = 0.01), and those with <3 training were more likely to be low frequency users than those with =>3 training (odd ratio = 5.05, P= 0.05). All variables significant in the first model remained significant in the second model. Impediments to the Use of Dermoscopy Among African Dermatologists Half (50%) of the respondents reported not using dermos- copy. Notable setbacks to the use of dermoscopy were lack of training, technical/expertise support and challenges with interpretation of dermoscopic findings followed by unavail- ability of dermatoscopes (Figure 2). A few of the respondents (5.6%) were not using dermos- copy in spite of having training. Reasons included: no access to a dermatoscopes (unable to buy personal ones) and lack of confidence in spite of training. Dermoscopy Training Some of the various training options by the respondents included hands on/on the job training, online/social media, conference, virtual, part of undergraduate/residency training and structured training (certification trainings). More than half of the respondents (52.6 %) had some form of train- ing while 47.4% had no training at all. The most commonly Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 5 Table 1. Association between country of practice and use dermoscopy Country of practice Non-users N (%) Users N (%) Total N (%) Nigeria 39(50.6) 38(49.4) 77(100) Ethiopia 11(91.7)a 1(8.3) 12(100) Ghana 4(66.7) 2(33.3) 6(100) South Africa 3(15) 17(85) a 20(100) Angola 1(50) 1(50) 2(100) Tanzania 3(100) 0(0) 3(100) Uganda 1(100) 0(0) 1(100) Kenya 2(100) 0(0) 2(100) Malawi 0(0) 1(100) 1(100) Tunisia 0(0) 4(100) a 4(100) Rwanda 1(100) 0(0) 1(100) Mozambique 1(100) 0(0) 1(100) Sudan 0(0) 1(100) 1(100) Senegal 5(83.3) 1(16.7) 6(100) Madagascar 4(100) a 0(0) 4(100) Cameroun 2(100) 0(0) 2(100) Guinea 1(100) 0(0) 1(100) Benin 2(100) 0(0) 2(100) Ivory coast 2(100) 0(0) 2(100) Mauritania 0(0) 1(100) 1(100) Egypt 7(28) 18(72) a 25(100) Maroc 7(35) 13(65) 20(100) Gambia 1(100) 0(0) 1(100) Congo 1(100) 0(0) 1(100) Total 98(50) 98(50) 196(100) F(P value) 53.86(<0.01) ‘a’ indicates a strong likelihood that the country is either a user or non-user of dermoscopy depending on its specific placement. reported mode of training was on the job training and hands-on training (Table 4). Reasons for not having dermos- copy training are highlighted in Figure 3. Determinants of training were country of practice (P < 0.001) and years of practice (P = 0.04). Interestingly, use and frequency of use of dermoscopy were significantly associated with the num- ber of training activities undertaken (Table 5). Awareness and Use of Guidelines and Techniques in Dermoscopy A greater proportion (78.6%) of those who had training on dermoscopy were aware of the existence of dermoscopic cri- teria for skin diseases. While 55.3% use them always, 34% use them sometimes. Commonest reasons for use included ensuring uniformity of diagnosis and providing more confi- dence in diagnosis while the commonest reason for non-use was poor knowledge of and difficulty remembering different criteria. Indications for Use of Dermoscopy and Perceived Usefulness of Dermoscopy The common indications for the use of dermoscopy are mostly pigmented lesions and non-tumoral dermatoses as summa- rized in Figure 4. Majority (82.5%) of the respondents with training believed that the use of dermoscopy had improved their dermatologic practice, 10.7% did not think it improved their practice while 1.9% did not know if it did. Dermos- copy was considered most useful for diagnosis (91.6%), le- sion monitoring (70.4%), treatment monitoring (61.4%), guidance for biopsy (60.2%) and considered least useful for patient education (1.2%) and hair transplantation (1.2%). On the perception on the usefulness of dermoscopy, ma- jority of the respondents (84.5%) believed that dermoscopy was comparable to clinical examination with the unaided eye and histopathology while 1.9% and 8.7% thought clin- ical examination and histopathology were superior to der- moscopy respectively. 6 Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 Table 2. Association between sociodemographic and other variables and use of dermoscopy Non-users N (%) Users N (%) Total N (%) X(P) Practice setting Public /government funded Teaching hospitals 54(55.1) 63(64.3) 117(59.7) 6.28(0.09) Public/ Government funded Federal Medical Centers 28(28.6) 14(14.3) 42(21.4) Private hospital 11(11.2) 16(16.3) 27(13.8) Private funded Teaching hospitals 5(5.1) 5(5.1) 10(5.1) Place of practice Urban 78(79.6) 84(85.7) 162(82.7) 1.60(0.44)Semi-urban 16(16.3) 10(10.2) 26(13.3) Rural 4(4.1) 4(4.1) 8(4.1) Gender Male 31(31.6) 23(23.5) 54(27.6) 1.63(0.21) Female 67(68.4) 75(76.5) 142(72.4) Current Cadre Intern 1(1) 0(0) 1(0.5) 2.11(0.54) Registrar/Junior resident 5(5.1) 6(6.1) 11(5.6) Senior Registrar/Senior Resident 17(17.3) 12(12.2) 29(14.8) Specialist/Consultant 75(76.5) 80(81.6) 155(79.1) Average number of patients seen in a day <10 18(18.4) 13(13.3) 31(15.8) 1.44(0.69) 10-20 55(56.1) 62(63.3) 117(59.7) 21-50 22(22.4) 21(21.4) 43(21.9) 51-100 3(3.1) 2(2) 5(2.6) How did you hear about dermoscopy? No prior knowledge 3(3.1) 0(0) 3(1.5) 6.55(0.25) Residency training 51(52) 65(66.3) 116(59.2) Conference 28(28.6) 22(22.4) 50(25.5) Graduate certificate and MSc dermatology 2(2) 2(2) 4(2) Colleagues 10(10.2) 6(6.1) 16(8.2) Online 4(4.1) 3(3.1) 7(3.6) Are you aware of guidelines or techniques to the use of dermoscopy in dermatology? Yes 1(1) 80(81.6) 81(41.3) 131.31(<0.01) No 97(99) 18(18.4) 115(58.7) Does your training center provide dermoscopes Yes 0(0) 33(33.7) 33(16.8) 39.68(<0.01) No 98(100) 65(66.3) 163(83.2) Conclusions This is the first report evaluating the use of dermoscopy and its determinants among dermatologists in Africa. The low response rate was comparable with those recorded in most of the studies on dermoscopy in the literature [5,11, 27,30]. Various nationwide surveys and pan-continental stud- ies from other continents reported dermoscopy use ranging from 56.9 % to 98% [5, 9-11,23-26,28-31]. Despite wide- spread awareness of its dermatological utility, dermoscopy use was predictably lower (50%) than in Western societies This observation aligns with the evolving role of dermos- copy in diagnosing skin conditions in individuals with darker skin phototypes, a population largely represented in Africa [21,22,32,33]. Historically, dermoscopy had been used exclusively for distinguishing neoplastic lesions from pigmented and non-pigmented benign lesions in lighter skin phototypes [34]. These dermatoses were previously consid- ered to be uncommon in skin of colour hence the erstwhile limitations to dermoscopy in the darker skin phototypes [21,22]. Secondly, dermatologic criteria for diagnosis of der- matosis in skin of colour have only recently been reported [21,22,32]. This may contribute to the limited use of der- moscopy in this region. Knowledge of dermatoscopic guidelines/criteria and techniques translates to confidence in Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 7 Table 3. Association between practice related factors and frequency of dermoscopy use Low frequency N (%) High frequency N (%) OR(CI) P value Average number of patients seen in a day <10 9(69.2) 4(30.8) 5.71(1.61-20.34) 0.01 10-20 22(35.5) 40(64.5) 0.75(0.29-1.91) 0.54 21-50 2(9.5) 19(90.5) 0.15(0.03-0.71) 0.01 51-100 0(0) 2(100) 0.37(0.01-8.12) 0.53 How did you hear about dermoscopy? Residency training 27(41.5) 38(58.5) 3.19(1.16-8.80) 0.02 Conference 3(13.6) 19(86.4) 0.24(0.06-0.88) 0.03 Graduate certificate and MSc 1(50) 1(50) 2.00(0.12-33.02) 0.31 Colleagues 1(16.7) 5(83.3) 0.37(0.04-3.34) 0.22 Online 1(33.3) 2(66.7) 0.98(0.08-11.27) 0.98 Are you aware of guidelines or techniques to the use of dermoscopy in dermatology? Yes 24(30) 56(70) 0.42(0.15-1.21) 0.11 No 9(50) 9(50) 2.33(0.82(-6.60) 0.11 Does your training center provide dermoscopes Yes 6(18.2) 27(81.8) 0.31(0.11-0.86) 0.02 No 27(41.5) 38(58.5) 3.19(1.16-8.80) 0.02 Has the use of dermoscopy changed your management of dermatologic conditions in any way? Yes 24(28.2) 61(71.8) 0.17(0.04-0.62) 0.01 No 7(63.6) 4(36.4) 4.10(1.11-15.23) 0.01 Don’t know 2(100) 0(0) 10.39(0.48-223.07) 0.12 Do you use existing dermoscopic criteria in the diagnosis of skin diseases? Yes 14(24.6) 43(75.4) 0.37(0.15-0.89) 0.02 No 5(83.3) 1(16.7) 11.42(1.27-102.37) 0.02 Sometimes 14(40) 21(60) 1.54(0.65-3.66) 0.32 What type of dermoscope do you use? Hand-held/Handyscope 28(37.3) 47(62.7) 2.14(0.71-6.41) 0.17 Videodermoscope 5(55.6) 4(44.4) 2.72(0.67-10.92 0.15 Both 0(0) 12(100) 0.06(0.01-1.11) 0.05 Don’t know 0(0) 2(100) 0.37(0.01-8.12) 0.53 Are you aware of any complications from the use of dermoscopes? Yes 11(44) 14(56) 1.82(0.71-4.63) 0.21 No 22(30.1) 51(69.9) 0.54(0.21-1.39) 0.21 CI = confidence interval; OR = odds ratio. dermoscopic diagnosis and was found to be strongly asso- ciated with use in this study (Table 3) as was observed in some other studies [23,27]. Dermoscopy is now applicable across all skin types, including darker skin. Understanding its principles, methods, terminology, reporting, and criteria in diverse skin tones is crucial for its effective use, as high- lighted by this study findings [21,22, 28, 30]. Undertaking training in dermoscopy, country of prac- tice and certain practice settings (public/government funded teaching hospitals) significantly correlated with use in this study and was in consonance with findings from several studies [9, 11, 27, 29]. Lack of training as a major bar- rier to the use of dermoscopy among the respondents in our study was also consistently observed in several other studies [29,30 ,31,35]. There is compelling evidence from several studies that training is key in promoting the use of dermoscopy [9,10,26-28]. Dermoscopy training in Africa was low when compared to the Western societies some with training rates as high as 98% [9,11,12,25]. While training was generally less prevalent in many sub-Saharan African countries, our study revealed that coun- tries with higher dermoscopy training rates (Egypt, South Africa, and Tunisia) may have well-structured dermoscopy training integrated into their curriculum or established as a standard practice in dermatology. This is evident in the sig- nificant association found between these countries and der- moscopy training. This emphasizes the low dermoscopy use, primarily due to limited training in these countries. Dermos- copy recent recognition in diagnosing darker skin explains this [21,22]. Integrating dermoscopy training in African curricula, along with raising awareness and offering diverse training opportunities, will enhance dermatologists skills. 8 Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 Figure 2. Reasons for not using dermoscopy Table 4. Association between type of training and use or non-use of dermoscopy use Users versus non-users Non-users N (%) Users N (%) Total N (%) Kind of training received On the job training 1(1.9) 52(98.1) 53(100) Hands-on 0(0) 53(100) 53(100) Virtual 0(0) 29(100) 29(100) Part of undergraduate/postgraduate training 4(9.8) 37(90.2) 41(100) Online/social media 0(0) 25(100) 25(100) Graduate certificate and MSc 0(0) 12(100) 12(100) Structured (certification) training 1(10) 9(90) 10(100) Conference/workshops 0(0) 6(100) 6(100) Chi-square(p-value) 13.79(0.05) The unavailability of dermatoscopes and the inability of training institutions to provide them posed significant challenges to dermoscopy use, contrary to findings in other studies where many respondents had access to dermato- scopes [5, 29]. In our study, the cost of dermatoscopes was also identified as a notable barrier, deviating from findings in other studies [9,36]. Unfortunately, dermatoscopes are not locally produced in most sub-Saharan African countries, leading to high costs due to shipping and import duties. In- terestingly, an Australian study revealed that despite respon- dents not owning personal dermatoscopes, practice centers supplied most of the devices used [36]. Dermatologists in academic Public/Government-funded Teaching Hospitals were more inclined to use dermoscopy compared to non-academic Public/Government-funded Federal Medical centers, which contrasts with findings in a French study [26]. This difference may be attributed to Teaching Hospitals involvement in dermatology research, academic programs, and residency training, which likely ne- cessitate modern diagnostic methods like dermoscopy. Addi- tionally, the availability of advanced medical equipment and referrals for complex cases requiring specialized diagnostic accuracy could drive the use of innovative diagnostic tools, including dermoscopy. Further studies are required to ex- plore this observation. In contrast to other studies that identified female gender, younger age, and years of experience as significant factors, our study did not find such associations [10,23, 27,30]. Nev- ertheless, our findings indicate that there are no gender or age constraints to dermoscopy use in our study population Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 9 Figure 3. Reasons for not undergoing dermoscopy training as was seen in one study, and further research is warranted to investigate the underlying reasons for this divergence [26]. Dermoscopy was more frequently utilized by respon- dents who had a higher patient load, had access to derma- toscopes, and held a positive view of dermoscopy diagnostic benefits while also adhering to diagnostic criteria. Dermatol- ogists with a higher patient load are more likely to encounter diverse skin lesions, making dermoscopy a valuable diagnos- tic tool. Access to dermatoscopes and a positive view of its diagnostic utility, along with adhering to criteria, indicate a better understanding and promote its frequent use. This mirrors previous research, showing a consistent trend in der- moscopy utilization [9,35]. An intriguing discovery was the higher dermoscopy us- age among residents compared to specialists/consultants, possibly due to younger individuals greater adoption of dig- ital technology. Residents are also more inclined to use diag- nostic aids, unlike experienced specialists. We observed that there was an increased use of der- moscopy by those who were exposed to frequent training Table 5. Association between the number of training and practice of dermoscopy Number of training >=3 <3 OR(CI) P value Use Non-users 0(0) 98(100) 0.01(<0.01-0.1) <0.01 Users 42(42.9) 56(57.1) 148(8.94-2454.56) <0.01 How often do you use a dermoscope? Never 0(0) 98(100) 0.01(<0.01-0.11) <0.01 Rarely (less than once in two weeks) 2(22.2) 7(77.8) 1.05(0.21-5.25) 0.95 Sometimes (once in a week or two) 7(29.2) 17(70.8) 1.61(0.62-4.18) 0.32 Often (2 or 3 times a week) 12(57.1) 9(42.9) 5.42(2.09-14.05) <0.01 Always (every working day) 21(47.7) 23(52.3) 5.69(2.69-12.05) <0.01 Frequency among users only (N = 98) Low frequency 9(27.3) 24(72.7) 0.36(0.14-0.90) 0.02 High frequency 33(50.8) 32(49.2) 2.75(1.11-6.81) 0.02 CI = confidence interval; OR = odds ratio. 10 Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 sessions which was not surprising as we felt that this trans- lated to increasing confidence in the use of dermoscopy with more dermoscopy training exposures [26,27]. These findings also reiterate the key role of continuous standardized and structured training incorporating dermoscopic guidelines and criteria. In contrast to several studies from other continents where dermoscopy is mainly used for distinguishing be- nign pigmented skin lesions from tumors, most of our re- spondents used dermoscopy for non-tumoral dermatoses ( Figure 4) [23, 26, 31,36]. This is possibly due to the rela- tively lower incidence of skin tumors in darker skin types. Recent research, including our own, suggests an increasing trend in dermoscopy use for various conditions, like in- flammatory and hair diseases, reflecting a growing aware- ness of dermoscopy utility in diagnosing non-tumoral skin diseases [5]. The underutilization of dermoscopy wide diagnostic po- tential, especially for vascular tumors, may be due to chal- lenges visualizing blood vessels in darker skin due to pigment interference. This is exacerbated by the limited data and il- lustrations of dermoscopic characteristics in dark skin, as ex- isting literature primarily focuses on features in lighter skin [15, 16,20]. This study limitations include potential responder bias from self-reported data in a voluntary online survey, possibly overestimating dermoscopy use and positive attitudes among specialists with specific interests or expertise in dermoscopy. Key factors such as training and familiarity with dermoscopic criteria may be more prevalent among participating derma- tologists who actively seek knowledge and information about dermoscopy. To mitigate this bias, future research employing random sampling and diverse representation of dermatolo- gists from varied backgrounds and practice settings in Africa. Dermoscopy is an evolving practice in Africa although its use is currently low. Challenges to its use include unavail- ability of dermatoscopes and lack of training. Provision of dermatoscopes in practice settings/institutions, promoting opportunities for training in dermoscopy in the dark skin, inclusion of dermoscopy training in dermatology training curricula and having dedicated workshops will improve der- moscopy use in Africa. Acknowledgements The authors are grateful to Professor Manal Bosseila who assisted with sending online forms to colleagues in Egypt and Drs. Perpetua Ibekwe (ASDV) and Enzo Errichetti for assist- ing with reaching out to other colleagues in Africa. References 1. Tromme I, Sacré L, Hammouch F, et al. Availability of digital dermoscopy in daily practice dramatically reduces the number of excised melanocytic lesions: results from an observational study. Br J Dermatol. 2012;167(4):778-786. DOI: 10.1111/j.1365 -2133.2012.11042.x. PMID: 22564185. 2. Vestergaard ME, Macaskill P, Holt PE, Menzies SW. Dermos- copy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol. 2008;159(3):669-676. DOI: 10.1111/j.1365-2133.2008.08713.x. PMID: 18616769. 3. Lallas A, Giacomel J, Argenziano G, et al. Dermoscopy in gen- eral dermatology: practical tips for the clinician. Br J Dermatol. 2014;170(3):514-526. DOI: 10.1111/bjd.12685. PMID: 24266695. Figure 4. Indications for using dermoscopy Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 11 Dermatology. 2007;214(1):3-5. DOI: 10.1159/000096904. PMID: 17191039. 19. Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP; In- ternational Dermoscopy Society Board members. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57(1):84-95. DOI: 10.1016/j.jaad.2006.02.051. PMID: 17482314. 20. Ezenwa E, Stein JA, Krueger L. Dermoscopic features of neo- plasms in skin of color: A review. Int J Womens Dermatol. 2021;7(2):145-151. DOI: 10.1016/j.ijwd.2020.11.009. PMID: 33937480. PMCID: PMC8072485. 21. Errichetti E, Ankad BS, Jha AK, et al. International Dermoscopy Society criteria for non-neoplastic dermatoses (general derma- tology): validation for skin of color through a Delphi expert consensus. Int J Dermatol. 2022;61(4):461-471. DOI: 10.1111 /ijd.15729. PMID: 34216025. 22. Ankad BS, Behera B, Lallas A, et al. International Dermoscopy Society (IDS) Criteria for Skin Tumors: Validation for Skin of Color Through a Delphi Expert Consensus by the “Imaging in Skin of Color” IDS Task Force. Dermatol Pract Concept. 2023;13(1):e2023067. DOI: 10.5826/dpc.1301a67. PMID: 36892378. PMCID: PMC9946051. 23. Alqahtani NN, AlBukhari FA. The use of dermoscopy among dermatologists in Riyadh, Saudi Arabia: A cross-sectional study. J Dermatol Dermatol Surg. 2021;25:30-32. DOI: 10.4103/jdds .jdds_58_20. 24. Bahadoran P, Malvehy J. Dermoscopy in Europe: coming of age. Br J Dermatol. 2016;175(6):1132-1133. DOI: 10.1111 /bjd.15128. PMID: 27996126. 25. Noor O 2nd, Nanda A, Rao BK. A dermoscopy survey to assess who is using it and why it is or is not being used. Int J Dermatol. 2009;48(9):951-952. DOI: 10.1111/j.1365-4632.2009.04095.x. PMID: 19702978. 26. Breton AL, Amini-Adle M, Duru G, Poulalhon N, Dalle S, Thomas L. Overview of the use of dermoscopy in academic and non-academic hospital centres in France: a nationwide survey. J Eur Acad Dermatol Venereol. 2014;28(9):1207-1213. DOI: 10.1111/jdv.12260. PMID: 23998395. 27. Engasser HC, Warshaw EM. Dermatoscopy use by US der- matologists: a cross-sectional survey. J Am Acad Dermatol. 2010;63(3):412-419:419.e1-2. DOI: 10.1016/j.jaad.2009.09.050. PMID: 20619490. 28. Wu TP, Newlove T, Smith L, Vuong CH, Stein JA, Polsky D. The importance of dedicated dermoscopy training during residency: a survey of US dermatology chief residents. J Am Acad Derma- tol. 2013;68(6):1000-1005. DOI: 10.1016/j.jaad.2012.11.032. PMID: 23374231. 29. Terushkin V, Oliveria SA, Marghoob AA, Halpern AC. Use of and beliefs about total body photography and dermatoscopy among US dermatology training programs: an update. J Am Acad Der- matol. 2010;62(5):794-803. DOI: 10.1016/j.jaad.2009.09.008. PMID: 20223561. 30. Burbidge T, Davidson W, Robertson L. Dermoscopy use by Cana- dian dermatologists and dermatology residents: a cross- sectional nationwide study. Br J Dermatol. 2017;177(5):e213-e214. DOI: 10.1111/bjd.15604. PMID: 28449184. 31. Nehal KS, Oliveria SA, Marghoob AA, et al. Use of and beliefs about dermoscopy in the management of patients with pig- mented lesions: a survey of dermatology residency programmes 4. Errichetti E, Stinco G. The practical usefulness of dermoscopy in general dermatology. G Ital Dermatol Venereol. 2015;150(5): 533-546. PMID: 26086412. 5. Butler TD, Matin RN, Affleck AG, Fleming CJ, Bowling JC. Trends in dermoscopy use in the UK: results from surveys in 2003 and 2012. Dermatol Pract Concept. 2015;5(2):29-38. DOI: 10.5826 /dpc.0502a04. PMID: 26114049. PMCID: PMC4462896. 6. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic ac- curacy of dermoscopy. Lancet Oncol. 2002;3(3):159-165. DOI: 10.1016/s1470-2045(02)00679-4. PMID: 11902502. 7. Zalaudek I, Argenziano G, Di Stefani A, et al. Dermoscopy in general dermatology. Dermatology. 2006;212(1):7-18. DOI: 10.1159/000089015. PMID: 16319467. 8. Hurley AR, Totty JP, Pinder RM. Dermoscopy as an adjunct to surgical excision of nonmelanoma Skin lesions: a system- atic review and Meta-analysis. J Clin Aesthet Dermatol. 2022 Sep;15(9):45-49. 9. Forsea AM, Tschandl P, Del Marmol V, et al. Factors driving the use of dermoscopy in Europe: a pan-European survey. Br J Der- matol. 2016 Dec;175(6):1329-1337. DOI: 10.1111/bjd.14895. PMID: 27469990. 10. Moulin C, Poulalhon N, Duru G, Debarbieux S, Dalle S, Thomas L. Dermoscopy use by French private practice dermatologists: a nationwide survey. Br J Dermatol. 2013;168(1):74-79. DOI: 10.1111/j.1365-2133.2012.11216.x. PMID: 22880932. 11. Venugopal SS, Soyer HP, Menzies SW. Results of a nationwide dermoscopy survey investigating the prevalence, advantages and disadvantages of dermoscopy use among Australian der- matologists. Australas J Dermatol. 2011;52(1):14-18. DOI: 10.1111/j.1440-0960.2010.00708.x. PMID: 21332687. 12. Kittler H, Marghoob AA, Argenziano G, et al. Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74(6):1093-1106. DOI: 10.1016/j .jaad.2015.12.038. PMID: 26896294. PMCID: PMC5551974. 13. Errichetti E, Zalaudek I, Kittler H, et al. Standardization of dermoscopic terminology and basic dermoscopic parameters to evaluate in general dermatology (non-neoplastic dermatoses): an expert consensus on behalf of the International Dermoscopy Society. Br J Dermatol. 2020;182(2):454-467. DOI: 10.1111 /bjd.18125. PMID: 31077336. 14. Soyer HP, Argenziano G, Zalaudek I, et al. Three-point check- list of dermoscopy. A new screening method for early detec- tion of melanoma. Dermatology. 2004;208(1):27-31. DOI: 10.1159/000075042. PMID: 14730233. 15. Errichetti E. Dermoscopy of common papulosquamous derma- toses varies between dark (III and IV) and very dark (V and VI) skin phototypes. Dermatol Ther. 2021;34(2):e14757. DOI: 10.1111/dth.14757. PMID: 33404194. 16. Errichetti E, Ankad BS, Sonthalia S, et al. Dermoscopy in gen- eral dermatology (non-neoplastic dermatoses) of skin of colour: a comparative retrospective study by the International Der- moscopy Society. Eur J Dermatol. 2020;30(6):688-698. DOI: 10.1684/ejd.2020.3928. PMID: 33319764. 17. Lallas A, Kyrgidis A, Tzellos TG, et al. Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea. Br J Dermatol. 2012;166(6):1198-1205. DOI: 10.1111/j.1365-2133.2012.10868.x. PMID: 22296226. 18. Bowling J, Argenziano G, Azenha A, et al. Dermoscopy key points: recommendations from the international dermoscopy society. 12 Original Article | Dermatol Pract Concept. 2024;14(2):e2024098 35. de Giorgi V, Trez E, Salvini C, et al. Dermoscopy in black people. Br J Dermatol. 2006;155(4):695-699. DOI: 10.1111/j.1365-2133 .2006.07415.x. PMID: 16965417. 36. Piliouras P, Buettner P, Soyer HP. Dermoscopy use in the next gen- eration: a survey of Australian dermatology trainees. Australas J Dermatol. 2014;55(1):49-52. DOI: 10.1111/ajd.12061. PMID: 23713814. in the United States. Melanoma Res. 2002;12(6):601-605. DOI: 10.1097/00008390-200212000-00010. PMID: 12459650. 32. Dogra S, Mittal A. Role of dermoscopy in the diagnosis of pig- mentary dermatoses in skin of color. Pigment Int. 2014;1(2):41. DOI:10.4103/2349-5847.147037. 33. de Giorgi V, Trez E, Salvini C, et al. Dermoscopy in black people. Br J Dermatol. 2006;155(4):695-699. DOI: 10.1111/j.1365-2133 .2006.07415.x. PMID: 16965417. 34. Tan E, Levell NJ. Regular clinical dermatoscope use with train- ing improves melanoma diagnosis by dermatologists. Clin Exp Dermatol. 2009;34(8):e876-e878. DOI: 10.1111/j.1365-2230 .2009.03629.x. PMID: 20055853.