Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 1 Patients’ Ability to Take Dermoscopic Follow-Up Images of Atypical Melanocytic Lesions With Smartphones: A Pilot Study Sofia Berglund1,2, John Paoli1,2, Petra Svensson3, Karin Terstappen3, Martin Gillstedt1,2, Johan Dahlén Gyllencreutz1,4 1 Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 2 Region Västra Götaland, Sahlgrenska University Hospital, Department of Dermatology and Venereology, Gothenburg, Sweden 3 Region Västra Götaland, Skaraborg Hospital, Department of Dermatology and Venereology, Skövde, Sweden 4 Department of Dermatology and Venereology, Frölunda Hospital, Gothenburg, Sweden Key words: Teledermatology, Dermoscopy, Atypical melanocytic lesion, Short-term monitoring, Smartphone Citation: Berglund S, Paoli J, Svensson P, Terstappen K, Gillstedt M, Dahlén Gyllencreutz J. Patients Ability to Take Dermoscopic Follow-Up Images of Atypical Melanocytic Lesions With Smartphones: A Pilot Study. Dermatol Pract Concept. 2024;14(4):e2024268. DOI: https://doi.org/10.5826/dpc.1404a268 Accepted: June 27, 2024; Published: October 2024 Copyright: ©2024 Berglund 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: Sofia Berglund, Department of Dermatology and Venereology, Sahlgrenska University Hospital, Gröna Stråket 16, 413 45 Gothenburg, Sweden. Telephone: +46 768 468 70 68. E-mail address: sofia.berglund@gu.se Introduction: Short-term teledermoscopic monitoring helps to distinguish early melanomas from nevi. As the incidence of melanoma is increasing, there are several benefits of patients’ taking their own dermoscopic images, but only a few previous studies have investigated the feasibility of this approach. Objectives: To examine patients’ ability to take evaluable dermoscopic images of atypical melanocytic lesions in need of short-term monitoring. Methods: Patients were asked to take follow-up images in their homes using a borrowed dermoscope and their own smartphone. It was investigated whether the management decision differed when assess- ing follow-up images taken by patients compared to follow-up images taken by hospital staff. Lesions were rated as either changed, unchanged, or in need of further monitoring. In addition, image quality and patients’ attitudes towards taking dermoscopic follow-up images were studied. Results: Ninety-five patients with 132 lesions completed the study. Images taken by hospital staff were of better quality than images taken by patients (P<0.001). A total of 24 dermoscopic images taken ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 Introduction Melanomas diagnosed at an early stage (≤1 mm in Breslow thickness) without ulceration have an excellent prognosis, with almost 100% melanoma-specific survival [1]. Although melanomas are often visible to the naked eye, early cases (in situ and thin melanomas) can be difficult to distinguish from nevi. Since melanomas change over time, early melano- mas can be identified by comparing sequential dermoscopic images (safety interval 2.5–4.5 months apart) of atypi- cal melanocytic lesions (AMLs) [2-4]. During short-term teledermoscopic monitoring, sequential dermoscopic images are examined by an expert in dermoscopy side-by-side on a computer screen instead of face-to-face [3]. Teledermoscopy is safe and effective for referral triaging, skin self-examination, and lesion monitoring [3, 5-8]. There are a variety of different hand-held dermoscopes available today, and as technology evolves, so does the image quality [9]. Tra- ditionally, dermoscopic images are taken by health care pro- fessionals. A previous study presented promising results when investigating patients’ ability to take dermoscopic follow-up images of AMLs during short-term monitoring using bor- rowed smartphones and dermoscopes under supervision [10]. The purpose of this study was to determine whether pa- tients were able to take evaluable dermoscopic follow-up images of AMLs for teledermoscopic short-term monitoring using a borrowed dermoscope and their own smartphone without supervision. The primary outcome was to compare the concordance between the assessment of lesion change made between follow-up images taken by patients and hospi- tal staff. Secondary outcomes were to compare image quality and to assess patients’ perceived difficulty when taking der- moscopic images with their own smartphone. The main hy- pothesis was that the assessment of lesion change would not differ between images taken by patients and hospital staff. Materials and Methods Participants Eligible patients (aged ≥18 years) with 1–3 AMLs suitable for short-term teledermoscopic monitoring were asked to participate in the study. They had to have access to a smartphone with a built-in camera, and if their lesion was situated on an inaccessible body part, they had to be able to ask a relative or friend for help. Exclusion criteria were patients with familial melanoma and lesions with any of the following criteria: high suspicion of melanoma, blue or gray color, nodular lesions, and lentiginous lesions in chron- ically sun-damaged skin. Recruitment was performed during 2021-2022 at Sahlgrenska University Hospital (Gothenburg, Sweden), Frölunda Specialist Hospital (Gothenburg, Sweden), and Skaraborg Hospital (Skövde, Sweden). Study Design Baseline clinical and dermoscopic images of AMLs planned for short-term teledermoscopic monitoring were taken by hospital staff during the first appointment. Hospital images were taken with either an iPhone SE, iPhone 8, or iPhone 11 smartphone (Apple Inc, USA) and a DermLite DL4 der- moscope (3Gen Inc, San Juan Capistrano, CA, USA). After 3–4.5 months, patients were asked to return to the hospital to take new sets of images in line with the current short- term monitoring procedure [3]. In addition, patients were instructed to take images at home with their own smart- phone and a borrowed DermLite HÜD dermoscope (3Gen Inc, San Juan Capistrano, CA, USA) 1–7 days prior to their second hospital visit (Figure 1). The dermoscope and its uni- versal connection device were sent to the patients by mail or handed to them at the first appointment. Simple oral instruc- tions on how to take dermoscopic images were given to the patients at the time of study inclusion. More detailed written instructions and a video showing how to attach the dermo- scope to a smartphone and how to take images were also made available to the patients. The importance of adding a large amount of immersion fluid to the lesion before it was photographed was emphasized in all instructions. Dermo- scopes were returned during the second hospital visit and the images were transferred to the hospital server. Management Decision The teledermoscopic comparisons between the baseline and the follow-up images were performed by experts in by patients (18.2%) were of poor quality and considered unsuitable for assessment at follow-up. In the remaining 108 lesions, the management decision was concordant in 95 cases (88.0%). Most pa- tients found the procedure to be easy to perform, and 76.0% of patients answered that they preferred self-photography. Conclusions: Self-photography for teledermoscopic evaluation of atypical melanocytic lesions is feasi- ble, but it results in worse image quality, which may lead to discordant evaluations. Dermoscopes used for this purpose need to be more user-friendly and maintain a higher technical standard. Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 3 teledermoscopy (J.P. at Sahlgrenska University Hospital, J.D.G. at Frölunda Specialist Hospital, and K.T. at Skaraborg Hospital) 1–7 days after the follow-up visit. First, the baseline image and the patient’s image were examined side-by-side on a computer screen. At this point, the examiner did not have access to the follow-up images taken by hospital staff. The le- sion in the images was rated as either (1) changed - proceed with excision, (2) unchanged, or (3) need for further moni- toring (i.e., the patient was asked to return to the hospital af- ter another 4–6 months to take additional follow-up images). Subsequently, the same teledermoscopy experts compared the baseline images and the follow-up images taken by hospital staff. Once again, the images of the same lesion were examined side-by-side on a computer screen, and the lesion was rated as either changed, unchanged, or in need of further monitoring. The final management decision was based solely on the images taken by hospital staff compared to the baseline images. Significant Change If a lesion demonstrated a significant change, the teleder- moscopist was asked to state what dermoscopic changes appeared. Examples of significant changes included morpho- logical changes (shape, border, color, size, or elevation) or the appearance of known dermoscopic melanoma features (e.g., dots/globules, vascular structures, multiple colors, or regression) [11]. An example of non-significant changes was a uniform increase or decrease in pigmentation due to sea- sonal tanning, dermoscopic lighting, or camera exposure. Image Quality The teledermoscopists also assessed the quality of the follow-up images according to the following classification: (1) high quality, (2) acceptable quality, or (3) poor quality. High-quality images were considered to be perfect or close to perfect, and images of acceptable quality could have flaws but were considered good enough to allow for a confident management decision, whereas poor quality images were con- sidered to be useless for this purpose. Lesions with images of poor quality were not included in the analyses of concordance. Patient Attitudes The patients’ attitudes towards taking images at home were also registered. Patients were asked to estimate on a visual analog scale of 0 (very easy) to 10 (very difficult) how easy/ difficult they perceived the technique to be. Furthermore, pa- tients were asked if they would prefer to return to the hos- pital to take follow-up images or take follow-up images at home in the event that they were to develop another lesion in need of short-term teledermoscopic monitoring. Statistical Analysis Since this was a pilot study, a power calculation was not performed prior to study initiation. Besides descriptive statistics, Fisher’s exact tests were used to compare propor- tions, Kruskal-Wallis tests were used to compare three or more groups, and Wilcoxon rank-sum tests were used for two-sample comparisons. P-values <0.05 were considered to be statistically significant. All statistical analyses were carried out with R version 3.5.3 (The R Foundation for Statistical Computing, Vienna, Austria). Results Patient and Lesion Characteristics A total of 106 patients with 157 lesions in need of short- term teledermoscopic monitoring were included in this study. Another 51 patients were asked to participate but de- clined. Eleven patients with 23 lesions were excluded during the course of the study (Figure 2). Another two lesions from two different patients who had several AMLs were excluded due to (1) images being taken of the wrong lesion (this pa- tient had a total of three lesions monitored), and (2) one out of two included AMLs not being photographed. Thus, data from a total of 95 patients with 132 lesions were analyzed. The age of the patients ranged from 19.9 to 79.7 years, and 63.2% were women (Table 1). The median size of the lesions was 5 mm, and the most common anatomical location of the AMLs was the back (Table 2). The time interval between the baseline and follow-up images taken by hospital staff ranged from 3.2 to 4.9 months (mean, 3.9 months). Lesion Change and Excisions Table 3 presents how many lesions were assessed as changed, unchanged, or in need of further monitoring when examin- ing follow-up images taken by patients and by hospital staff. A total of 24 lesions had dermoscopic follow-up images of Figure 1. Timeline of the Study Procedures and Visits. 4 Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 dysplastic nevi, one was a high-grade dysplastic nevus, and one was a non-dysplastic nevus. Image Quality A total of 18.2% of the patients’ images were of poor quality and could not be used for the evaluation of concordance. Images taken by hospital staff were of better quality than im- ages taken by patients (P<0.001). Images taken by hospital staff were predominantly of high quality, while images taken by patients were primarily of acceptable quality (Table 5). When analyzing images taken by patients, neither their age (P=0.062) nor the lesion location (P=0.17) affected image quality. Examples of images with different quality are pre- sented in Fig. 4. Patients’ Attitudes Most patients (76.6%) would prefer to take their own follow-up images instead of returning to the hospital if required in the fu- ture. There was no age difference between patients who wished to return to the hospital to take images and patients who pre- ferred to take their own dermoscopic images (P=0.98). Patient sex was also equally distributed between the groups (P=1.0). The degree of perceived difficulty varied, but 61.1% answered less than two on the visual analog scale (Figure 5). too poor a quality for assessment and were therefore not taken into account when looking at concordance. Among the remaining 108 lesions, the management decision was concordant for 95 of them (88.0%). Figure 3 displays an example of a discordant assessment. Of the five lesions as- sessed as changed when examining follow-up images taken by patients, two were assessed as changed, one as in need of further monitoring, and two as unchanged when examining the hospital images. Of the six lesions assessed as changed when examining the hospital images, two were assessed as changed, one as in need of further monitoring, and two as unchanged when examining the follow-up images taken by patients (n.b., the sixth lesion did not have follow-up im- ages of good enough quality to make a management deci- sion) (Table 4). Another six lesions were considered to have changed after further monitoring for another 4–6 months and were excised then. Histopathological Diagnoses None of the excised lesions were melanomas. Out of the six lesions excised after the initial short-term monitoring time interval, four were low-grade dysplastic nevi, and two were non-dysplastic nevi. Out of the six lesions excised af- ter further monitoring of 4–6 months, four were low-grade Figure 2. Flowchart of the Inclusion Process. Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 5 decisions due to poor quality, and significant dermoscopic changes were sometimes only observed in the hospital staff images and not in the patient images. The few discordant assessments of change may partially be explained by differences in technology between the der- moscopes used by the patients and the hospital staff. The borrowed dermoscope was less expensive than other dermo- scopes and was chosen since it could be purchased in larger quantities and distributed to patients. Although no dermo- scopes were damaged or lost during this study, there is a possible risk of this occurring when lending dermoscopes to patients. There were also technological differences between the dermoscopes. The hospital staff’s dermoscope allows contact dermoscopy, unlike the borrowed dermoscope. When taking images with a non-contact dermoscope, the distance to the camera’s focal point within a lesion might differ slightly and cause parts of a lesion to be unfocused [12]. Further, just a slight movement of the patient could lead to an image turning out blurry, especially when using non-contact der- moscopy [12]. However, by using non-contact dermoscopy, alteration in blood perfusion due to pressure is avoided [13]. Another example of technical differences was that al- though both dermoscopes used polarized light, shiny white Discussion In the present study, we demonstrate that patients with AMLs in need of short-term monitoring are often able to acquire evaluable dermoscopic images with a borrowed dermoscope and their own smartphones. In addition, patients’ attitudes towards taking their own images were predominantly posi- tive, and the majority preferred this approach to returning to the hospital to take follow-up images. Nevertheless, al- most one-fifth of the images did not allow for management Table 1. Patient Characteristics. Characteristics Patients, n 95 Age, years Mean 48.7 Median 48.4 Range 19.9–79.7 Sex, n (%) Female 60 (63.2) Male 35 (36.8) Heredity for melanoma, n (%) None or unknown 73 (76.9) First-degree relative 13 (13.7) Second-degree relative 9 (9.5) Prior melanoma diagnosis, n (%) None 72 (75.8) One melanoma 21 (22.1) Two melanomas 1 (1.1) Three melanomas 1 (1.1) Skin type, n (%) I 8 (8.4) II 45 (47.4) III 41 (43.2) IV 1 (1.1) Nevus count, n (%) 0–25 37 (38.9) 26–50 26 (27.4) 51–100 15 (15.8) >100 17 (17.9) Number of nevi >5 mm, n (%) 0 25 (26.3) 1–5 50 (52.6) 6–10 8 (8.4) >10 11 (11.6) NA 1 (1.1) Abbreviation: n: number of patients; NA: data not available. Table 2. Atypical Melanocytic Lesion Characteristics. Characteristics, n Total number of lesions 132 Lesions per hospital, n (%) Sahlgrenska University Hospital 64 (48.5) Skaraborg Hospital 41 (31.1) Frölunda Specialist Hospital 27 (20.5) Maximum diameter, mm Mean 5.9 Median 5.0 Range 2.0–12.0 Location, n (%) Back 62 (47.0) Chest/abdomen 36 (27.3) Lower extremities 22 (16.7) Upper extremities 9 (6.8) Acral areas 3 (2.3) Head and neck 0 (0) Lesions per patient Mean 1.4 Median 1.0 Range 1.0–3.0 Abbreviation: n: number of lesions. 6 Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 possible dermoscopic changes were difficult to assess at the first follow-up visit. The optional mid-to-long-term moni- toring adds slightly more complexity and subjectivity to the short-term monitoring procedure but subsequently spares even more patients from unnecessary excisions. No melano- mas were diagnosed in our study, which may be explained by the small number of monitored lesions. The hypothesis that dermoscopic images for short-term monitoring can be taken by patients themselves was first introduced by Wu et al. in 2015 [10]. In line with the find- ings of Wu et al., our results show a relatively high, but not perfect, diagnostic concordance between examinations of dermoscopic images taken by patients and those taken by hospital staff. In contrast, Boyce et al. presented a slightly lower concordance (69%) when comparing the diagnostic assessment of clinical images of melanocytic lesions taken by patients with smartphones with face-to-face assess- ments [16]. structures were more apparent with the hospital staff’s der- moscope. The optimal type of dermoscopic instrumentation and technique used by patients themselves still needs to be determined. To ensure the safety of the short-term monitor- ing process, technical aspects between different dermoscopes must be studied further [14]. Moreover, legal and ethical is- sues such as safe data transfer and guaranteed secrecy needs to be addressed before implementation [15]. Short-term teledermoscopic monitoring of AMLs has previously been shown to be safe and accurate. An excision rate of 9.1% in the present study (six lesions after short- term monitoring and an additional six lesions after further monitoring) was similar to the excision rate observed in a previous study by Berglund et al. (8.6%) but slightly lower than the excision rates observed by Altamura et al. and Men- zies et al. (18.7 –22.3%) [2-4]. This discrepancy might be ex- plained by the option of continued monitoring after another 4–6 months, which was offered to selected patients in which Table 3. Assessment of Lesion Change during Short-Term Monitoring. Patient image Hospital image Changed – proceed with excision, n 5 6 Unchanged, n 90 111 Need of further monitoring, n (thereafter excised) 13 14 (6) Uncertain due to poor image quality, n 24 1 n, number of lesions. Figure 3. Example of a lesion with discordant assessments based on the patient’s and the hospital staff’s images. (a) Baseline image taken by hospital staff. (b) Follow-up image taken by the patient four months after the baseline image. (c) Follow-up image taken by hospital staff four months after the baseline image. A tendency towards shiny white structures was noted in the follow-up image taken by hospital staff (arrows). Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 7 Table 4. Characteristics of Excised Atypical Melanocytic Lesions. Lesions 1-6 were Excised after Short-Term Monitoring, and Lesions 7-12 were Excised after Further Monitoring. N Sex Location Max diameter, mm New dermoscopic feature(s) Management decision based on patient image Histopathological diagnosis 1 Female Back 5 Gray/blue color Changed – proceed with excision Low-grade dysplastic nevus 2 Female Lower extremities 3 Dots & globules Changed – proceed with excision Low-grade dysplastic nevus 3 Male Back 3 Gray/blue color and dots and globules Further monitoring Low-grade dysplastic nevus 4 Female Back 6 Atypical network Poor image quality Non-dysplastic nevus 5 Male Back 7 Gray/blue color Unchanged Non-dysplastic nevus 6 Female Chest/abdomen 12 Tendency towards shiny white structures Unchanged Low-grade dysplastic nevus 7 Female Back 6 Dots & globules Further monitoring Low-grade dysplastic nevus 8 Male Back 5 Gray/blue color and dots and globules Further monitoring High-grade dysplastic nevus 9 Female Back 6 Dots & globules and atypical network Further monitoring Low-grade dysplastic nevus 10 Male Chest/abdomen 10 Atypical network Further monitoring Low-grade dysplastic nevus 11 Female Chest/abdomen 4 Atypical network Unchanged Non-dysplastic nevus 12 Male Chest/abdomen 6 Dots & globules Unchanged Low-grade dysplastic nevus Abbreviations: N: number; mm: millimeter; NA: data not available. Table 5. Assessment of Image Quality. Patient image Hospital image P value High quality, n 50 116 <0.001 Acceptable quality, n 58 15 Poor quality, n 24 1 n=number of lesions. Images taken by patients were primarily of acceptable or high quality. Nevertheless, approximately one in five images taken by patients were of poor quality compared to only one percent of images taken by hospital staff. Previous studies on image quality of images taken by patients show varying but more promising results. Manahan et al. found that less than 1% of dermoscopic images taken by patients were of poor quality [17], and Janda et al. found that 12% of dermoscopic images taken by patients were of poor quality [18]. Partic- ipants in these two studies used technically advanced and expensive dermoscopes. In addition, they investigated the diagnostic feasibility of skin self-examination and not short- term monitoring with sequential dermoscopic images, which may require a higher quality standard to be able to assess. In the study by Wu et al., only one out of 29 dermoscopic images were of too poor a quality to use for short-term mon- itoring assessment [10]. Poor image quality might be due to lack of training and experience among patients. Perhaps an instructive checklist could aid patients in acquiring images of better quality [19]. Most patients had a positive attitude towards taking der- moscopic follow-up images themselves and found the pro- cedure to be easy to perform. However, since only 62.5% of the patients asked to participate actually completed the study, there might have been a selection bias with regards to which patients were included. Perhaps patients with lesions 8 Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 Figure 4. Examples of images of different quality. (A-C) Images taken by patients and (D) image taken by hospital staff. (A) Image rated as having poor quality, (B) image with acceptable quality, and (C-D) high-quality images. Figure 5. Patients’ perceived difficulty with taking dermoscopic images with a borrowed dermoscope (0 meaning ‘very easy’ and 10 meaning ‘very difficult’). VAS, visual analog scale. Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 9 dermoscopy monitoring for the diagnosis of melanoma. Arch Dermatol. 2008;144(4):502-6. DOI: 10.1001/archderm.144.4 .502. PMID: 18427044. 3. Berglund S, Bogren L, Paoli J. Diagnostic accuracy and safety of short-term teledermoscopic monitoring of atypical melano- cytic lesions. J Eur Acad Dermatol Venereol. 2020;34(6):1233-9. DOI: 10.1111/jdv.16144. PMID: 31838783. 4. Menzies SW, Gutenev A, Avramidis M, Batrac A, McCarthy WH. Short-term digital surface microscopic monitoring of atypi- cal or changing melanocytic lesions. Arch Dermatol. 2001; 137(12):1583-9. DOI: PMID: 11735708. 5. Janda M, Horsham C, Koh U, et al. Redesigning Skin Cancer Early Detection and Care Using a New Mobile Health Applica- tion: Protocol of the SKIN Research Project, a Randomised Con- trolled Trial. Dermatology. 2019;235(1):11-8. DOI: 10.1159 /000493729. PMID: 30404085. 6. Janda M, Horsham C, Vagenas D, et al. Accuracy of mobile digital teledermoscopy for skin self-examinations in adults at high risk of skin cancer: an open-label, randomised controlled trial. Lancet Digit Health. 2020;2(3):e129-e37. DOI: 10.1016 /s2589-7500(20)30001-7. PMID: 33334577. 7. Dahlen Gyllencreutz J, Paoli J, Bjellerup M, et al. Diagnostic agreement and interobserver concordance with teledermoscopy referrals. J Eur Acad Dermatol Venereol. 2017;31(5):898-903. DOI: 10.1111/jdv.14147. PMID: 28150389. 8. Dahlén Gyllencreutz J, Johansson Backman E, Terstappen K, Paoli J. Teledermoscopy images acquired in primary health care and hospital settings - a comparative study of image qual- ity. J Eur Acad Dermatol Venereol. 2018;32(6):1038-43. DOI: 10.1111/jdv.14565. PMID: 28850732. 9. Blum A, Jaworski S. Clear differences in hand-held dermoscopes. J Dtsch Dermatol Ges. 2006;4(12):1054-7. DOI: 10.1111 /j.1610-0387.2006.06128.x. PMID: 17176414. 10. Wu X, Oliveria SA, Yagerman S, et al. Feasibility and Efficacy of Patient-Initiated Mobile Teledermoscopy for Short-term Monitoring of Clinically Atypical Nevi. JAMA Dermatol. 2015;151(5):489-96. DOI: 10.1001/jamadermatol.2014.3837. PMID: 25629626. 11. Kittler H, Pehamberger H, Wolff K, Binder M. Follow-up of me- lanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypi- cal nevi, and common nevi. J Am Acad Dermatol. 2000;43(3): 467-76. DOI: 10.1067/mjd.2000.107504. PMID: 10954658. 12. Jütte L, Yang Z, Sharma G, Roth B. Focus stacking in non-contact dermoscopy. Biomed Phys Eng Express. 2022;8(6). DOI: 10.1088 /2057-1976/ac9847. PMID: 36206663. 13. Heratizadeh A, Fricke D, Meinhardt-Wollweber M, Roth B, Werfel T. Non-contact remote digital dermoscopy - new perspectives on differential diagnosis of inflammatory skin diseases. J Eur Acad Dermatol Venereol. 2020;34(3):e125-e6. DOI: 10.1111/jdv.16056. PMID: 31710132. 14. Ackermann DM, Smit AK, Janda M, et al. Can patient-led surveillance detect subsequent new primary or recurrent mela- nomas and reduce the need for routinely scheduled follow-up? A protocol for the MEL-SELF randomised controlled trial. Trials. 2021;22(1):324. DOI: 10.1186/s13063-021-05231-7. PMID: 33947444. 15. Mars M, Morris C, Scott RE. Selfie Telemedicine - What Are the Legal and Regulatory Issues? Stud Health Technol Inform. 2018;254:53-62. DOI: PMID: 30306957. in inconvenient or intimate areas and patients with poor technical skills chose not to participate. A prior survey study by Diethei et al. highlighted the emotional aspects of taking images of one’s own body. Two-thirds of the patients pre- ferred to send images to their doctor, but if the image was of an intimate body part, or the potential diagnosis had a poor prognosis, they preferred to see a doctor in person [20]. The option to return to the hospital to take follow-up im- ages must always be available for these patients as well as for patients without smartphones and patients with lesions on hard-to-reach body sites without a partner to help out with the photography. In line with our results, several other studies demonstrate that patients’ attitudes are overall pos- itive when it comes to sending images to their physician for assessment, especially for detecting changes within a lesion over time [21-23]. If patients were to take their own follow-up images, it could enhance patient involvement in their own care, improve convenience by not having to travel to the hospital, and ease health care professionals’ scheduling. There are a few limitations to this study. Firstly, it was not possible to blind the teledermoscopists to which image they were assessing since the patient images had a slightly different tone of color. Therefore, the teledermoscopists had to evaluate the patient images first without access to the hos- pital images to minimize bias. Secondly, the evaluation of significant change within a lesion and the rating of image quality are subjective assessments [8]. However, subjectivity is inevitable when it comes to visual assessments and does therefore mimic real-world clinical practice. Furthermore, all assessments were made by single observers at single points in time. Lastly, this was a pilot study in which no melanomas were found. However, this study may help to prepare power calculations in future studies with larger study populations. In conclusion, we show that self-photography for teledermoscopic evaluation of atypical melanocytic lesions is feasible, but it often results in worse image quality. Pa- tients have a positive attitude towards taking dermoscopic follow-up images with smartphones. Due to the risk of dis- cordant assessments, a lower threshold for change may need to be applied when examining images taken by patients. In addition, dermoscopes borrowed by patients probably need to be more user-friendly and maintain a higher technical standard. References 1. Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol. 2009;27(36):6199-206. DOI: 10.1200/jco.2009.23.4799. PMID: 19917835. 2. Altamura D, Avramidis M, Menzies SW. Assessment of the optimal interval for and sensitivity of short-term sequential digital 10 Original Article | Dermatol Pract Concept. 2024;14(4):e2024268 20. Diethei D, Colley A, Kalving M, et al. Medical selfies: Emotional impacts and practical challenges. Conference Proceedings - 22nd International Conference on Human-Computer Interaction with Mobile Devices and Services: Expanding the Horizon of Mobile Interaction, MobileHCI 2020; 2020. 21. Kong F, Horsham C, Rayner J, et al. Consumer Preferences for Skin Cancer Screening Using Mobile Teledermoscopy: A Qualitative Study. Dermatology. 2020;236(2):97-104. DOI: 10.1159/000505620. PMID: 32126557. 22. Dieng M, Smit AK, Hersch J, et al. Patients’ Views about Skin Self-examination after Treatment for Localized Mela- noma. JAMA Dermatology. 2019;155(8):914-21. DOI: 10.1001 /jamadermatol.2019.0434. PMID: 23. Koh U, Horsham C, Soyer HP, et al. Consumer Acceptance and Expectations of a Mobile Health Application to Photograph Skin Lesions for Early Detection of Melanoma. Dermatology. 2019;235(1):4-10. DOI: 10.1159/000493728. PMID: 30404081. 16. Boyce Z, Gilmore S, Xu C, Soyer HP. The remote assessment of melanocytic skin lesions: a viable alternative to face-to-face consultation. Dermatology. 2011;223(3):244-50. DOI: 10.1159 /000333363. PMID: 22095005. 17. Manahan MN, Soyer HP, Loescher LJ, et al. A pilot trial of mobile, patient-performed teledermoscopy. Br J Derma- tol. 2015;172(4):1072-80. DOI: 10.1111/bjd.13550. PMID: 25418126. 18. Janda M, Loescher LJ, Soyer HP. Enhanced skin self-examination: a novel approach to skin cancer monitoring and follow-up. JAMA Dermatol. 2013;149(2):231-6. DOI: 10.1001/jamadermatol .2013.1218. PMID: 23426490. 19. Koh U, Betz-Stablein B, O’Hara M, et al. Development of a Checklist Tool to Assess the Quality of Skin Lesion Images Acquired by Consumers Using Sequential Mobile Teleder- moscopy. Dermatology. 2021:1-8. DOI: 10.1159/000515158. PMID: 33849022.