Examination of lesions (including dermoscopy) without contact with the patient is associated with improper management in about 30% of equivocal melanomas

BACKGROUND. In clinical practice, decisions regarding management of a pigmented skin lesion are based on morphologic examination, as well as on anamnestic, emotional, and medicolegal aspects. In some cases, the "ugly duckling" sign may be an indication for excision of a morphologically featureless melanoma. Therefore, examination of pigmented skin lesions based on clinical and dermoscopic images, without contact with the patient, may be associated with a not negligible risk of incorrect lesion management. OBJECTIVE. In this study, we tried to assess to what extent lesion management based on purely morphologic examination diverges from optimal management based on in vivo examination with direct contact with the patient, lesion history, and clinical and dermoscopic evaluation. METHODS. The study included clinical and dermoscopic images of 100 diagnostically equivocal pigmented lesions, including 20 early melanomas and 5 pigmented basal cell carcinomas consecutively referred for surgery; the images were reviewed by six dermatologists who specialize in melanoma screening and were previously trained in dermoscopy. RESULTS. The percentage of melanomas correctly classified was less than 50% both for naked eye and combined examination. Regarding lesion management, only about 70% of malignancies (melanomas and basal cell carcinomas) are correctly referred for surgery by observers. Similar results have been obtained focusing on melanoma (72.5%). CONCLUSION. Facing difficulties in diagnosing pigmented skin tumors, lesion management based on the morphology of the lesion, even including dermoscopic images, but without direct contact with the patient, diverges greatly from the gold standard management established by face-to-face examination and comports a not negligible risk of leaving a melanoma unexcised.