Dermatology: Practical and Conceptual Review | Dermatol Pract Concept. 2025;15(4):5208 1 Training Primary Care Practitioners In Dermoscopy Diagnostic Algorithms Enhances Diagnostic Accuracy and Triage of Suspected Skin Cancer: Scoping Review Evidence Alexandre Ladet1, Sandra Lawton2, Michael J Boffa2,3 1 Département Universitaire de Médecine Générale, Faculté de Médecine, Université de Montpellier, France 2 University of South Wales, UK 3 Department of Dermatology, Mater Dei Hospital, Malta Key words: Primary care, Skin cancer, Melanoma, Dermoscopy, Diagnostic algorithm Citation: Ladet A, Lawton S, Boffa MJ. Training Primary Care Practitioners In Dermoscopy Diagnostic Algorithms Enhances Diagnostic Accuracy and Triage of Suspected Skin Cancer: Scoping Review Evidence. Dermatol Pract Concept. 2025;15(4):5208. DOI: https://doi. org/10.5826/dpc.1504a5208 Accepted: March 17, 2025; Published: October 2025 Copyright: ©2025 Ladet 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: Alexandre Ladet. 10 rue du Dr Gardes. 30700 Uzès. France. ORCID ID: 0009-0002-6931-2769. E-mail: docteur. ladet@cabinetmedical.fr Introduction: In many Western countries, access to a dermatologist can be difficult, while the inci- dence of skin cancer has risen steadily over the past 50 years. Objective: We reviewed the published literature to determine whether training primary care practi- tioners (PCPs) in dermoscopy through brief interventions based on diagnostic algorithms could im- prove patient care by improving their diagnostic accuracy of suspect lesions. Methods: A scoping review of the literature was conducted, focusing on studies published in the pe- riod 2003–2023 that assessed the ability of low-experienced PCPs to triage suspicious dermatological lesions using dermoscopic diagnostic algorithms. Regarding outcomes, we focused on quantitative variables relevant to screening practice in general practice, including sensitivity, specificity, referrals to specialists, and unnecessary lesion excisions. Results: Of the 926 studies initially identified, 13 were eventually selected: 10 cross-sectional ob- servational studies and three randomized controlled trials. The studies were carried out in North America (N=6), Western Europe (N=4), and Australia (N=3). There was heterogeneity in the training interventions and the criteria used to assess diagnostic accuracy of PCPs after training; however, all studies showed an improvement in this parameter. The preferred algorithms for training PCPs were the 3-point checklist, the 7-point checklist, and the Triage Amalgamated Dermoscopy Algorithm. Conclusion: This review demonstrates the value of training PCPs in dermoscopic diagnostic algo- rithms through short courses to improve triage of suspicious lesions. However, it is still necessary to de- fine a territorial organization, a precise working framework and limits for PCPs who take on this role. ABSTRACT 2 Review | Dermatol Pract Concept. 2025;15(4):5208 Introduction Many Western countries are facing a shortage of health- care professionals, including in the field of dermatology. In Europe, the ageing physician population and lack of replace- ments is straining healthcare systems [1]. North America has not been spared either, with a predicted shortage of primary and secondary care physicians by 2033 in the USA [2] and a chronic shortage of physicians in rural areas in Canada [3]. In many Western countries with publicly-funded healthcare systems, the waiting time to see a dermatologist is long, in- creasing pressure on PCPs to acquire new skills to fill the gap [4–7]. Furthermore, skin cancer incidence is increasing, particularly in developed countries with ageing populations. The prognosis for melanoma, which is the most serious of these cancers, depends on the Breslow thickness and can therefore be improved by early detection and appropriate management [8, 9]. Dermoscopy has become an established tool in dermatol- ogy that facilitates diagnosis, particularly of pigmented skin lesions. It is widely used in practice throughout the world. In Europe, the most recent observational studies show a us- age rate among dermatologists of between 94.6% and 99% [10-12]. A very recent questionnaire-based study conducted in Greece showed that dermoscopy is used in more than 80% of clinical situations [13]. Dermoscopy could also be useful in primary care for identifying suspicious lesions and prior- itizing their management while reducing unnecessary exci- sions and referrals. Teledermoscopy could further improve triage accuracy. However, dermoscopy is only beneficial when performed by trained operators [14-16]. Algorithms can be used to train non-experts in dermoscopic screening, providing acceptable diagnostic sensitivity and specificity [17]. Various algorithms, such as the ABCD rule, Menzies method, 3-point and 7-point checklists, CASH algorithm, BLINCK, and TADA (Table 1) have, to varying degrees, been validated for use by dermoscopy operators [18-24]. Strength- ening training of PCPs in dermatology and promoting der- moscopy practice could help address the skin cancer burden; however, it is important to assess whether training PCPs in dermoscopic algorithms improves their diagnostic accuracy. Additionally, identifying scientifically robust and suitable dermoscopic algorithms for PCP training is necessary. Method A scoping review was conducted following the PRISMA ex- tension reference checklist focusing on the analysis of der- matological lesions suspicious for cancer using dermoscopy algorithms [25]. The selected algorithms were the 3-point and 7-point checklists, Menzies method, ABCD rule, CASH, BLINCK, and TADA [18-24] (Table 1). The review specifically looked at primary care settings and practitioners with little dermoscopy experience. Studies involving specialists, hospi- tals, other algorithms, or benign lesions were excluded. Searches were conducted in the following databases: MEDLINE, EMBASE, PASCAL, Cochrane Library, National Institute for Health Research Dissemination Centre, Camp- bell Library of Systematic Reviews, and the HealthSTAR da- tabase for grey literature. The use of the PICO method, categorizing subjects into Population, Intervention, Control, and Outcome, was em- ployed in the research strategy. The selection of keywords considered synonyms, alternative formulations, acronyms, and spelling variations [26]. The search was limited to the period 2003–2023, and only articles in English, French, Italian, Spanish, or German were reviewed. Most studies available were observational and of low evidence. Therefore, we included all studies up to level 3b of the Oxford Centre for Evidence-Based Medicine classification [27]. Regarding outcomes, we focused on quantitative vari- ables relevant to screening practice in general practice, in- cluding sensitivity, specificity, referrals to specialists, and unnecessary excisions. To assess strengths and weaknesses, we used a generic method for evaluating articles, which in- cluded eight evaluation criteria, using critical appraisal tools proposed by the Oxford Centre for Evidence-Based Medicine [28]. Finally, we used an interpretative method to analyze and summarize the results obtained. The lack of consistent data in publications made it challenging to use quantitative methods for analysis. Results Selection of Studies and Data Collected The seven selected databases were searched between March and July 2023, identifying 926 studies potentially relevant to the research topic. The selection process was carried out in successive stages, reducing the working sample to 39 studies, of which 12 fully meeting the pre-defined criteria were retained. One additional study emerged after repeat- ing the same selection process on the 912 references cited in the last 39 studies assessed. In the end, 13 studies were selected (Figure 1); of these, 10 were observational studies and three were controlled trials (Table 2). The studies were conducted between 2005 and 2021 in North America (N=6), Western Europe (N=4), and Australia (N=3) [23, 29-40]. Of the sample of studies collected by our method, only the 13 selected fully met our inclusion and exclusion criteria. We only selected studies that aimed to evaluate the diagnostic accuracy of lesions suspected of being cancerous by inexpe- rienced PCPs who had received a short training course and used dermoscopy by means of algorithms. Review | Dermatol Pract Concept. 2025;15(4):5208 3 The population of PCPs in the studies was heterogeneous: 11 studies observed a population that was 100% primary care, while two observed a mixed population. Three stud- ies included nurses, and one included students. Seven studies observed practitioners with little experience of dermatology and dermoscopy, while the other six studies observed pop- ulations with varying levels of experience. The number of participants in the individual studies varied (range 4–293; mean 76, median 61). Three studies that observed performance in real clinical situations included only practitioners with a sufficient volume of skin cancer screening activity. The number of studies utilizing the various dermoscopy algorithms were as follows: TADA – five; 3-point checklist – three; 7-point checklist – three; Menzies method – three; ABCD rule – two; BLINCK – one. Of these studies, one compared BLINCK, the 3-point checklist, and the Menzies method, while another compared the 7-point checklist, the ABCD rule, pattern analysis, and the Menzies method. Table 1. Overview of Algorithms Utilized in the Included Studies. Full name Abbreviation Description 3-point checklist None Using this algorithm, the operator looks for 7 signs of malignancy in the pigmented lesion. Two points are given for each of the three major criteria: atypical pigment network, blue-white veil and atypical vascular pattern and one point for each of the four minor criteria: irregular streaks, blotches or globules and regression structures. A score of 3 or more identifies a melanoma with a sensitivity of 95% and a specificity of 75%.. 7-point checklist None Using this algorithm, the operator looks for 7 signs of malignancy in the pigmented lesion: atypical pigment network, blue-white veil, atypical vascular pattern, streaks, blotches, globules, all irregularly distributed and regression structures. It is a weighted scoring system. The signs are divided into 2 categories: major signs and minor signs, which are assigned a score of 2 or 1 respectively. A score of 3 or more identifies a melanoma with a sensitivity of 95% and a specificity of 75%. Menzies method None The principle of this algorithm is that to be suspicious for melanoma, the lesion must not have a symmetrical pattern or a single colour, and it must have at least one feature that is considered a warning sign: blue-white veil, pseudopods, scar-like depigmentation, multiple brown dots, radial streaming, peripheral black globules, peppering and multiple colours. The colours considered by this algorithm are black, light and dark brown, red, blue and grey. ABCD rule None A scoring tool with parameters such as asymmetry in 2 axes (0-2 points), border in 8 sectors (0-8 points), number of colours (1-6 points) and number of dermoscopic structures (1-5 points). The score for each parameter is then weighted by a coefficient and the values are added together to give the final score. Scores below 4.75 indicate a benign lesion, scores above 5.45 indicate a melanoma and intermediate scores indicate at least the need for lesion monitoring. Colour, Architecture, Symmetry, and Homogeneity CASH This algorithm is similar to the ABCD rule but also considers architecture. It evaluates colour (blue, red, black, dark brown, tan or white), architecture, symmetry and homogeneity. The architecture is assessed by the operator’s overall impression of whether it is ordered or not. Each criterion is scored on a scale from 2 to 17. A score of 8 or more indicates melanoma with a sensitivity of 98% and a specificity of 68%. Benign, Lonely, Irregular, Nervous, Change and Known BLINCK The BLINCK algorithm is a simplified method designed for PCPs. The checklist mixes macroscopic clinical and dermoscopic items. The first clinical step is to determine whether the lesion is benign in which case the process is stopped. The other steps are used to produce a score. A score of 2 or more indicates the need for referral or biopsy. Triage Amalgamated Dermoscopy Algorithm TADA The TADA is designed for PCPs with little experience of dermoscopy. Its aim is not to make a diagnosis, but simply to triage between lesions for which the patient should be reassured and those for which they should be referred to a specialist or biopsied. It dispenses with the first stage of differentiation between melanocytic and non-melanocytic lesions using the 2-step algorithm. In this sense, it makes it possible to include NMSCs in the lesions to be referred or biopsied. It consists of 3 steps. The first aims to eliminate 3 types of commonly encountered benign lesions. The second looks for disorganised patterns and the third looks for clues associated with malignant lesions. The sensitivity of this algorithm for all types of cancer is 94.6% and the specificity is 72.5%. 4 Review | Dermatol Pract Concept. 2025;15(4):5208 lesions were only early-stage melanomas. The number of im- ages analyzed ranged from 30 to 200, (mean 74, median 55). Outcomes Four cross-sectional studies found that PCPs without expe- rience in dermatological oncology or dermoscopy showed significantly improved diagnostic accuracy (range 18–54%) for skin cancer screening from dermoscopic images after re- ceiving training in skin cancer basics and TADA. The PCPs had increased sensitivity and stable or increased specificity in their diagnoses. One comparable study which, however, used the 7-point checklist, found the same outcome apart from a significant decrease in performance for benign lesions. An- other similar study compared the performance of different practitioner subpopulations and showed no difference except that dermatologists had better specificity. The sensitivity and specificity values for PCPs (93.7% and 72.1%, respectively) were consistent with those reported in previous studies. Two studies compared the effect of teaching different algorithms on diagnostic accuracy. In both studies, assess- ment was based on high-resolution photographs selected by experts. One study evaluated the difference between the BLINCK, 3-point checklist and Menzies method, and the purely clinical method. The use of BLINCK showed a The learning interventions varied. In nine studies, par- ticipants received face-to-face training, and in three studies they received training using various computer media, CD- ROM, web or smartphone, or books; one study did not clearly indicate the teaching method. Three studies utilized mixed types of training. The duration of face-to-face training ranged from one to 10 hours (mean three hours 40 minutes, median two hours 40 minutes). All included an introduction to dermatological oncology and dermoscopy before focusing on the chosen algorithm. Only five studies assessed lesions in clinical practice by PCPs. Four of them assessed lesions in real-life conditions by the practitioner. A minimum of 235 and a maximum of 2,548 lesions were assessed (mean 899, median 406). The reference comparators varied, including pathology, expert opinion, teledermoscopy, or absence of evolution over time. The last study evaluated the impact of a dermoscopy diag- nostic algorithm training on referral numbers. The study du- rations ranged from six to 17 months (mean 10.5 months, median eight months). In the other eight studies, the clini- cian assessed the lesions using high-resolution photographs, with clinical information in four of them. The photographs provided covered all types of skin cancer, except one study, which included only pigmented lesions, and the malignant Figure 1. Flowchart of study selection. Review | Dermatol Pract Concept. 2025;15(4):5208 5 T ab le 2 c on ti nu es T ab le 2 . P ro fil e of S el ec te d St ud ie s. A rt ic le T yp e Po pu la ti on A lg or it hm In te rv en ti on L es io ns C om pa ri so n O ut co m e Se iv er lin g et a l. 20 21 U SA O bs er va ti on st ud y, C ro ss - se ct io na l • 10 0% P C P • L ow e xp er ie nc e • 96 p ar ti ci pa nt s T A D A • 12 0 m in In -P er so n G en er al it ie s • 60 m in W eb A lg or it hm • Im ag es • N o cl in ic al in fo rm at io n • A ll ty pe s of t um ou rs • 30 im ag es B ef or e vs a ft er • Si gn ifi ca nt in cr ea se o f ac cu ra cy f or b en ig n an d m al ig na nt le si on s C yr e t al . 20 21 U SA O bs er va ti on st ud y, C ro ss - se ct io na l • 10 0% P C P • V er y lo w e xp er ie nc e • 32 % S tu de nt s • 12 % N ur se s • 31 p ar ti ci pa nt s T A D A • 90 m in in -p er so n w or ks ho p • Im ag es • N o cl in ic al in fo rm at io n • A ll ty pe s of t um ou rs • 60 im ag es B ef or e vs a ft er • Si gn ifi ca nt im pr ov em en t in t es t re su lt s re ga rd le ss o f su bp op ul at io n Sa w ye rs e t al . 20 20 C an ad a O bs er va ti on st ud y, C ro ss - se ct io na l • 10 0% P C P • 31 p ar ti ci pa nt s • Sp ec ia l i nt er es t in s cr ee ni ng di ab et es , B P, o st eo po ro si s • N o ex pe ri en ce in de rm at ol og y T A D A • In -P er so n sl id es s ho rt pr es en ta ti on • Im ag es • C lin ic al in fo rm at io n • A ll ty pe s of t um ou rs • 10 0 im ag es • B ef or e vs a ft er • T A D A 1 st s te p on ly is a ss es se d • Si gn ifi ca nt im pr ov em en t in t es t re su lt s • W om en d id b et te r th an m en • Si gn ifi ca nt in cr ea se in s pe ci fic it y (- 33 % o f un ne ce ss ar y ex ci si on o r re fe rr al s) • Si gn ifi ca nt in cr ea se in s en si bi lit y fo r al l m al ig na nc ie s Se iv er lin g et a l. 20 19 U SA O bs er va ti on st ud y, C ro ss - se ct io na l • 10 0% P C P • 59 p ar ti ci pa nt s • 8 N ur se s • Sp ec ia l i nt er es t in de rm at ol og y • L ow e xp er ie nc e in de rm os co py T A D A • 1h a bo ut T A D A + as pe ct o f be ni gn le si on s • Im ag es • N o cl in ic al in fo rm at io n • A ll ty pe s of t um ou rs • 60 im ag es B ef or e vs a ft er • Si gn ifi ca nt im pr ov em en t in t es t re su lt s re ga rd le ss o f su b- po pu la ti on • Si gn ifi ca nt in cr ea se in s en si bi lit y • St ab ili ty o f s pe ci fic ity fo r al l l es io ns b ut si gn ifi ca nt in cr ea se o f s pe ci fic ity fo r 3 ty pe s of be ni gn le si on s (d er m at ofi br om a, s eb or rh ei c ke ra to si s, a ng io m a) R ob in so n et a l. 20 18 U SA R C T • 10 0% P C P • Su ffi ci en t vo lu m e of p at ie nt s • 89 p ar ti ci pa nt s 3- po in t ch ec kl is t • 3 se ss io ns : 2 0 m in , 1h , 1 h • Sm ar tp ho ne • N ot hi ng a bo ut N M SC • O bs er ve d in c lin ic al pr ac ti ce • R ef er ra ls a ss es sm en t • 6 m on th s R ef er ra ls as se ss m en t 3 m on th s be fo re v s 3 m on th s af te r • Si gn ifi ca nt r ed uc ti on o f nu m be r of r ef er ra ls fo r be ni gn le si on s fo r tr ai ne d pa rt ic ip an ts • Si gn ifi ca nt in cr ea se o f nu m be r of m el an om a re fe rr al s fo r tr ai ne d pa rt ic ip an ts • N o ef fe ct o n N M SC r ef er ra ls Se ck er e t al . 20 17 N et he rl an ds O bs er va ti on st ud y, C ro ss - se ct io na l • 10 0% P C P • L ow e xp er ie nc e • 29 3 pa rt ic ip an ts 7- po in t ch ec kl is t • 1 da y In -P er so n w or ks ho p • Bo ok p ro vi de d • Im ag es • C lin ic al in fo rm at io n • A ll ty pe s of t um ou rs • 40 im ag es B ef or e vs a ft er • Si gn ifi ca nt in cr ea se o f ac cu ra cy f or a ll le si on s ex ce pt n ae vi a ft er t ra in in g • Si gn ifi ca nt im pr ov e of th er ap eu tic s tr at eg y fo r al l l es io ns in cl ud in g al l m al ig na nt le si on s af te r tr ai ni ng e xc ep t f or n ae vi R og er s et a l. 20 16 U SA O bs er va ti on st ud y, C ro ss - se ct io na l • M ix ed • 34 .2 % P C P • 42 .3 % N o tr ai ni ng • 23 .3 % N o ex pe ri en ce • 12 0 pa rt ic ip an ts T A D A • 1 da y in -p er so n w or ks ho p • Im ag es • C lin ic al in fo rm at io n • A ll ty pe s of t um ou rs • 50 im ag es • D er m at ol og is ts vs P C P • E xp er ie nc ed v s no n ex pe ri en ce d • Se ns it iv it y 94 .8 % • Sp ec ifi ci ty 7 2. 3% • N o si gn ifi ca nt d if fe re nc es b et w ee n su b- po pu la ti on s ex ce pt in g sp ec ifi ci ty o f de rm at ol og is ts 6 Review | Dermatol Pract Concept. 2025;15(4):5208 A rt ic le T yp e Po pu la ti on A lg or it hm In te rv en ti on L es io ns C om pa ri so n O ut co m e K oe lin k et a l. 20 14 N et he rl an ds R C T • 10 0% P C P • 53 p ar ti ci pa nt s 7- po in t ch ec kl is t • 4h g en er al tr ai ni ng f or a ll • 6h e xt ra co ur se a bo ut de rm os co py f or on e ar m • O bs er ve d in c lin ic al pr ac ti ce • Se co nd ar y as se ss m en t by 2 e xp er ts v ia te le de rm at ol og y • Te rt ia ry a ss es sm en t if e xc is io n or f ac e- to - fa ce c on su lt at io n w it h de rm at ol og is t ne ed ed • 40 0 pa ti en ts 4 37 le si on s • 17 m on th s N ak ed e ye v s de rm os co py • O R o f co rr ec t di ag no si s w it h de rm os co py co m pa re d w it h na ke d ey e: 1 51 • Sa m e O R f or m el an om as o nl y: 5 52 • R R : 1 25 ( pr ob ab ili ty o f co rr ec t di ag no si s is 25 % h ig he r w it h de rm os co py ) B ou rn e et a l. 20 12 A us tr al ia O bs er va ti on st ud y, C ro ss - se ct io na l • 10 0% P C P • 4 pa rt ic ip an ts o nl y in cl ud in g 1 nu rs e • V ar ia bl e ex pe ri en ce • B L IN C K • 3- po in t ch ec kl is t • M en zi es m et ho d • O nl y B L IN C K is t au gh t • M et ho d of te ac hi ng is n ot kn ow n • Im ag es • C lin ic al in fo rm at io n pr ov id ed o nl y af te r as se ss m en t us in g 3p C he ck th en M en zi es • A ll ty pe s of t um ou rs b ut se le ct io n of le si on s • 50 im ag es M et ho d vs m et ho d in cl ud in g na ke d- ey e as se ss m en t • N o di ff er en ce s be tw ee n cl in ic ia ns • B L IN C K s ho w ed a s ig ni fic an t hi gh er se ns ib ili ty t ha n ot he r m et ho d • M en zi es m et ho d an d cl in ic al a ss es sm en t sh ow ed a s ig ni fic an t hi gh er s pe ci fic it y M en zi es e t al . 20 09 A us tr al ia O bs er va ti on st ud y, C ro ss - se ct io na l • 10 0% P C P • L ow e xp er ie nc e • Su ffi ci en t vo lu m e of p at ie nt s • 63 p ar ti ci pa nt s M en zi es m et ho d • Te xt bo ok an d C D -R om pr ov id ed • 2h in -p er so n w or ks ho p • O bs er ve d in c lin ic al pr ac ti ce • Se co nd ar y as se ss m en t by pa th ol og y or e xp er t or n o ch an ge f or b en ig n le si on s • Su sp ic io us p ig m en te d le si on s on ly • 37 4 le si on s • 8 m on th s • N ak ed e ye v s de rm os co py • N ak ed e ye v s D er m os co py + SD D I • B en ig n pi gm en te d le si on /m el an om a ra ti o si gn ifi ca nt d ec re as e fr om 9 5/ 1 to 3 7/ 1 w it h de rm os co py a lo ne a nd t o 33 /1 w it h de rm os co py + S D D I • N on s ig ni fic an t im pr ov em en t of s en si ti vi ty an d sp ec ifi ci ty f or m el an om a di ag no si s be tw ee n na ke d- ey e ex am in at io n an d de rm os co py a lo ne • Si gn ifi ca nt im pr ov em en t in c on fid en ce o f di ag no si s (n ak ed e ye v s de rm os co py ) • Si gn ifi ca nt im pr ov em en t of s en si ti vi ty w it h de rm os co py + S D D I Sp ec ifi ci ty u nc ha ng ed • M el an om a’ s m ea n th ic kn es s is n ot si gn ifi ca nt ly d if fe re nt a ft er w ai ti ng 3 m on th s fo r SD D I se co nd p ic tu re T ab le 2 . P ro fil e of S el ec te d St ud ie s. ( co nt in ue d) Review | Dermatol Pract Concept. 2025;15(4):5208 7 G ri m al di e t al . 20 09 I ta ly O bs er va ti on st ud y, C ro ss - se ct io na l • 10 0% P C P • 13 p ar ti ci pa nt s A B C D r ul e • W eb -t ra in in g • O bs er ve d in c lin ic al p ra ct ic e • Se co nd ar y as se ss m en t by e xp er ts u si ng te le de rm os co py • 19 7 pa ti en ts 2 35 le si on s • 5 m on th s • N ak ed -e ye v s de rm os co py • N ak ed -e ye + de rm os co py v s te le de rm os co py • Si gn ifi ca nt c ha ng e in O R • C lin ic al v s D er m os co py 0 35 • C lin ic al v s Te le de rm os co py 0 18 • D er m os co py v s Te le de rm os co py 0 52 A rg en zi an o et a l. 20 06 I ta ly an d Sp ai n R C T • 10 0% P C P • Su ffi ci en t vo lu m e of p at ie nt s • 73 p ar ti ci pa nt s 3- po in t ch ec kl is t • In -P er so n • 2h , c lin ic al A B C D r ul e • 2h , a lg or it hm • O bs er ve d in c lin ic al pr ac ti ce • Se co nd ar y as se ss m en t by 2 ex pe rt s th en e xc is io n if ne ed ed • 25 22 p at ie nt s 25 48 le si on s • 16 m on th s • N ak ed e ye v s de rm os co py • PC P vs e xp er t • Im pr ov em en t of P PV , N PV a nd s en si ti vi ty • St ab ili ty o f sp ec ifi ci ty • G oo d ac cu ra cy f or N M SC e ve n if t he al go ri th m is n ot d es ig ne d fo r D ol ia ni ti s et a l. 20 05 A us tr al ia O bs er va ti on st ud y, C ro ss - se ct io na l • M ix ed • 57 .4 % P C P • M ai nl y w it h ex pe ri en ce • 61 p ar ti ci pa nt s • 7- po in t ch ec kl is t • A B C D R ul e • Pa tt er n A na ly si s • M en zi es m et ho d • C D -R om pr ov id ed • Im ag es • N o cl in ic al in fo rm at io n • Pi gm en te d le si on s on ly • E ar ly s ta ge m el an om a on ly • 20 0 im ag es A lg or it hm v s al go ri th m • B es t se ns it iv it y an d ac cu ra cy f or M en zi es m et ho d • B es t sp ec ifi ci ty f or c lin ic al e xa m in at io n • H et er og en eo us r es ul ts d ep en di ng o n le si on 8 Review | Dermatol Pract Concept. 2025;15(4):5208 effective [41]. However, there is a strong presumption in fa- vor of involving health professionals in melanoma screening to promote early diagnosis and thus reduce associated mor- tality [42]. A study in France found that training a portion of PCPs in melanoma management significantly reduced the proportion of late diagnoses (Breslow thickness >3 mm) in their practice [43]. From our review it is clear that short training courses for PCPs on skin tumors and diagnostic dermoscopy can lead to improved diagnostic performance, earlier detection of skin cancer, and reduction in unnecessary excisions and referrals. It is therefore reasonable to recommend implementing edu- cational measures and encourage the use of dermoscopy in primary care, especially given the ageing population, increas- ing skin cancer incidence, and strained healthcare systems. Teaching Format By studying published findings concerning the training of PCPs in dermatology, we consider that the positive results in our review are linked to the common characteristics of the teaching utilized. Indeed, it appears that short, interactive, practical dermoscopy training courses utilizing algorithms are effective in increasing awareness of dermatological on- cology among PCPs. Furthermore, the available evidence suggests that the best format is interactive teaching, available online, designed by expert dermatologists in close collabora- tion with PCPs, and covering the practical management of the lesions observed. Other types of teaching have had more mixed results [17, 44-49]. Durability of Training Interventions This question remains, as few studies have been conducted for longer than six months. One study suggested that re- fresher courses are necessary to maintain the benefits of training. However, one Dutch study showed that the effects of dermato-oncology training did not fade over nine months without any refresher training [38, 50, 51]. Nevertheless, we know that humans’ ability to perform complex tasks dete- riorates over time and that refresher training is one way to counteract this phenomenon [52, 53]. In the more specific field of dermoscopy in PCPs, a recent study confirms this de- terioration after a short period (one year) [54]. We therefore suggest that a continuing education program, preferably in a short online format, is a reasonable option for maintaining the benefits of training, particularly for PCPs who perform dermoscopy on a regular basis. Reproducibility in Real Life of Studies Using Images Only It is reasonable to ask whether assessing diagnostic accu- racy on photographs is a coherent approach. The recent development of teledermoscopy, although requiring further significant improvement in sensitivity, while the Menzies method or the pure clinical method retained the best spec- ificity. The methodology of the intervention was poorly de- scribed. The population was small (four participants), and the photographs showed all types of lesions. The other study compared the diagnostic accuracy of the 7-point checklist, ABCD rule, pattern analysis, and Menzies method. Only 57.4% of the study population were PCPs, with varying levels of experience. Only pigmented lesions were evaluated. The cancers were all early-stage melanomas. The results were very heterogeneous, depending on the type of lesion. The Menzies method showed the best sensitivity and diag- nostic accuracy. The best specificity was obtained by exam- ining macroscopic images only. Five studies assessed the diagnostic accuracy of PCPs in a real-life situation; two were cross-sectional studies, which evaluated dermoscopy versus naked eye examination using the Menzies method or the ABCD rule algorithms. The for- mer study focused on suspicious pigmented lesions, showing a significant reduction in referrals for these lesions by us- ing dermoscopy, further improved by the combined use of Sequential Digital Dermoscopic Imaging (SDDI). However, sensitivity and specificity for melanoma diagnosis were not improved. The combination with SDDI only significantly improved sensitivity for melanoma detection. The use of der- moscopy in this study also improved clinicians’ diagnostic confidence. The latter study looked more broadly at diagno- sis of all lesion types and showed a significant improvement in the odds ratio in favor of dermoscopy, further improved by the use of teledermoscopy. The other three studies were RCTs investigating the diagnostic skills of PCPs trained in the 3-point checklist or 7-point checklist algorithms for any type of lesion. The first one showed a significant improvement in the odds ratio in favor of a correct diagnosis with der- moscopy. This increase is particularly relevant for diagnosing melanoma. The second showed a significant improvement in sensitivity, negative predictive value, and positive predictive value, while specificity remained stable. Diagnostic accu- racy for non-melanoma skin cancers (NMSCs) increased, although the 3-point checklist algorithm was not designed for this purpose. The third study focused on the number of referrals three months before and three months after train- ing, showing a significant reduction in benign lesion referral and a significant increase in melanoma referrals for trained participants, with no effect on NMSC referrals. Discussion Introducing Dermoscopy in Primary Practice There are currently too few trials of melanoma screening to be able to say with certainty that implementing a large- scale screening program in the general population would be Review | Dermatol Pract Concept. 2025;15(4):5208 9 varies worldwide but is generally limited [59-60]. It therefore seems that, although the assessment of suspicious lesions by PCPs using clinical and dermoscopic tools has proved its worth, there is still a long way to go before this practice becomes widespread. Factors influencing dermoscopy use by PCPs were identified in a recent qualitative study conducted in the UK, which showed that easy access to training and support in teaching dermoscopy build confidence in PCPs and may be the main game changer [61]. However, the cost of purchasing a dermoscope can be a barrier [38]. This sug- gests that a small group of motivated PCPs should be trained and provided with the necessary tools, while maintaining a link with continuing education and expert support. On the other hand, despite its clear potential, the role of PCPs in diagnosing cutaneous tumors has limitations compared to experts [34-36], and it is important to define the boundar- ies and framework for their practice. Furthermore, it would appear logical that PCPs involved in skin cancer screening should be able to communicate directly with experts for ad- vice when necessary. Scope for Future Research Research on the triage of skin lesions by PCPs to address the skin cancer burden is incomplete. Future research required includes evaluating the TADA algorithm under real clini- cal conditions, exploring the role of nurses and other non- physician healthcare professionals in triage, assessing the cost-effectiveness of SDDI devices, investigating alternative training methods for PCPs, and considering the organization of PCPs with extended roles. Qualitative studies on the im- pact of these changes on workload and patient care are also needed. Furthermore, the role of teledermoscopy, which has recently developed with the advance of computer systems, can be considered. The benefits of this practice on the diagnostic accuracy of online consultations have been demonstrated, al- though standardization efforts will be needed in the future to limit the heterogeneity of practice. When used by a trained PCP, teledermoscopy can introduce a second level of triage to minimize unnecessary face-to-face consultations [15,55,62]. Finally, the use of artificial intelligence algorithms to triage suspicious lesions is even more recent and has shown prom- ising results in the diagnosis of skin cancer. AI can assist in tasks that involve comparing patterns over time. However, at its current stage of development, AI cannot completely re- place the clinician’s diagnostic approach [63-66]. Strengths and Limitations This study was based on a well-designed methodology to minimize bias. The principal investigator’s perspective as a PCP adds relevance to the qualitative analysis. The study in- cludes a sufficient amount of diverse material to meet the objectives and provide recommendations for professional validation, appears promising [15,55]. The good results of clinical practice studies after similar interventions also sup- port the results of studies that have evaluated PCPs using images alone. It is known that dermoscopy supports clini- cal examination but does not replace it and that clinical ex- amination has better specificity than dermoscopy [17]. All proposed interventions included a teaching component on dermatological oncology in general, with workshops includ- ing a simulation component. This mixed teaching format thus seems to be the one to replicate to maximize the chances of adapting the training to future practice. Best Algorithm Three algorithms, namely, the 3-point checklist, 7-point checklist, and TADA, were highlighted for teaching purposes in the 13 selected studies. These algorithms were frequently used and consistently showed positive results in improving diagnostic accuracy. The 3-point and 7-point checklists were used in trials with robust designs, while TADA was evaluated in observational studies. All three algorithms demonstrated diagnostic performance, even when used by relatively inex- perienced practitioners. TADA was specifically designed for PCPs and seems well-suited for triaging suspicious skin le- sions [34]. However, large-scale studies under real conditions are still needed. Our review accepted all algorithms in its inclusion criteria. We chose to highlight the 3-point checklist because in this review it was associated with studies with the highest level of evidence. In addition, we find it easy to use and teach, which is important to encourage PCPs to use dermoscopy. Furthermore, we believe that TADA occupies a special place because it is specifically designed for use by PCPs by avoiding the preliminary phase of detection of me- lanocytic lesions by the 2-step algorithm. Its purpose is not so much to make an accurate diagnosis but rather to triage lesions and is relevant to all types of skin cancer. Future Role for PCPs The adoption of dermoscopy by PCPs and their role in man- aging skin cancer is still limited. As most of the studies in this review focused on physicians with an interest in der- matology, the results may not be fully representative of the wider community. In Australia, where skin cancer is a major public health concern [56], dermatology has a special GPwSI (General Practitioner with a Special Interest) status, with PCPs who have an interest in skin cancer taking the lead in skin cancer screening locally and acting as a link between primary and secondary care [57]. This status also exists in the UK with the GPwER (Gen- eral Practitioner with an Extended Role) [58]. However, even among such motivated practitioners, there may be barriers to accessing training [51]. Surveys show that dermoscopy use among PCPs without a specific interest in dermatology 10 Review | Dermatol Pract Concept. 2025;15(4):5208 Résultats - Dir Rech Etudes L’Evaluation Stat. 2020;1140:1-5. Accessed July 3, 2023. https://drees.solidarites-sante.gouv.fr/ 7. Legentil T. Évaluation Des Connaissances En Dermatologie Des Internes En Médecine Générale Du Languedoc-Roussillon et Évaluation de Leurs Besoins En Formation : Enquête Épidé- miologique Descriptive Par Questionnaire Informatisé. PhD. Université de Montpellier. Faculté de Médecine.; 2018. Accessed March 18, 2023. http://www.sudoc.abes.fr/cbs//DB=2.1/SET=1 /TTL=1/SHW?FRST=1 8. Urban K, Mehrmal S, Uppal P, Giesey RL, Delost GR. The global burden of skin cancer: A longitudinal analysis from the Global Burden of Disease Study, 1990–2017. JAAD Int. 2021;2:98-108. DOI:10.1016/j.jdin.2020.10.013 PMID:34409358 9. Jones OT, Ranmuthu CKI, Hall PN, Funston G, Walter FM. Rec- ognising Skin Cancer in Primary Care. Adv Ther. 2020;37(1): 603-616. DOI:10.1007/s12325-019-01130-1 PMID:31734824 10. Moulin C, Poulalhon N, Duru G, Debarbieux S, Dalle S, Thomas L. Dermoscopy use by French private practice dermatologists: a nationwide survey: Dermoscopy use by French private practice dermatologists. Br J Dermatol. 2013;168(1):74-79. DOI:10.1111/j.1365-2133.2012.11216.x PMID:22880932 11. 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. Published online April 30, 2015:29-38. DOI:10.5826/dpc.0502a04 PMID:26114049 12. Zoutendijk J, Siem D, Argenziano G, et al. The daily use of der- moscopy in the Netherlands: Eur J Dermatol. 2022;32(6):736- 742. DOI:10.1684/ejd.2022.4377 PMID:36856393 13. Sgouros D, Routsi E, Evangelodimou A, et al. Use of Der- moscopy among Greek Dermatologists in Everyday Clinical Practice: A National Questionnaire-Based Study. J Clin Med. 2024;13(4):972. DOI:10.3390/jcm13040972 PMID:38398285 14. Marghoob A, Braun R, Malvehy J. Introduction. In: Marghoob A, Braun R, Malvehy J, eds. Atlas of Dermoscopy. 2nd ed. In- forma Healthcare; 2012:1. 15. Jones OT, Jurascheck LC, van Melle MA, et al. Dermoscopy for melanoma detection and triage in primary care: a system- atic review. Br Med J Open. 2019;9(8):e027529. DOI:10.1136 /bmjopen-2018-027529 PMID:31434767 16. 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. Published online June 2008:669- 676. DOI:10.1111/j.1365-2133.2008.08713.x PMID:18616769 17. Dinnes J, Deeks JJ, Chuchu N, et al. Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults. Cochrane Database Syst Rev. 2018;12(12):CD011902. DOI:10.1002/14651858.CD011902.pub2 PMID:30521682 18. Weiger U, Burgdorf W, Stolz W. ABCD rule. In: Marghoob A, Braun R, Malvehy J, eds. Atlas of Dermoscopy. 2nd ed. Informa Healthcare; 2012:113-117. 19. Menzies S. Menzies method. In: Marghoob A, Braun R, Malvehy J, eds. Atlas of Dermoscopy. 2nd ed. Informa Health- care; 2012:118-123. 20. Argenziano G. Three-point checklist. In: Marghoob A, Braun R, Malvehy J, eds. Atlas of Dermoscopy. 2nd ed. Informa Health- care; 2012:118-123. 21. Argenziano G. Seven-point checklist and the seven rules not to miss melanoma incognito. In: Marghoob A, Braun R, Malvehy J, eds. Atlas of Dermoscopy. 2nd ed. Informa Healthcare; 2012:118-123. practice. However, we acknowledge several limitations, in- cluding the inability to use cross-methods due to a single in- vestigator. Furthermore, the choice of search algorithm and language limitations could have introduced selection bias. The decision to focus on the last 20 years, made to highlight recent teaching techniques and modern technology, led to the exclusion of one study even if this did not contradict the review’s conclusions. Furthermore, the relative heterogeneity of the populations of PCPs in our review may suggest an ad- ditional weakness; however, as dermoscopy is rarely taught to PCPs and primary care trainees, it is reasonable to assume that all participants in fact started from the same low level of dermoscopy expertise prior to training [67-70]. Conclusions The increasing incidence of skin cancer and the shortage of doctors have led to a need for PCPs to participate in skin cancer screening using dermoscopy. However, there are bar- riers to doing so, including limited access to training and equipment. One proposed solution is a coordinated practice model where PCPs with an interest in dermatology take the lead at a practice and/or territory level. Additionally, nurses and other non-physician healthcare professionals could also be involved in carrying out screening. Teledermoscopy and AI lesion analysis techniques could be further options. 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