Derm Dispatch: Rethinking Dermoscopy Training to Improve Melanoma Detection

Dermoscopy should be treated as a core clinical competency in dermatology training—not an optional skill—according to Michael Christopher, MD, who says stronger education and more deliberate examination practices could help clinicians recognize malignancies that are easily missed by the unaided eye.

In a recent Derm Dispatch conversation with Dermatology Times, Renata Block, MMS, PA-C, spoke with Christopher about gaps in dermoscopy education, cognitive biases that can influence lesion assessment, and practical changes clinicians can make to improve melanoma detection.

For Christopher, one case illustrates the problem particularly clearly. After presenting clinicians with clinical and dermoscopic images of a 2-mm lesion on the cheek of a 21-year-old patient, fewer than 20% of respondents to his poll indicated that they would biopsy it. The lesion was ultimately melanoma in situ.

“Regardless of the age, this was a melanoma,” Christopher said, arguing that recognition should not change simply because the patient is young.

Making Dermoscopy a Core Residency Competency

The poll highlighted what Christopher sees as a larger educational gap: Dermoscopy does not receive the same intensity of training during residency as other areas of dermatology that may play a less prominent role in clinicians’ everyday practice.

He pointed to dermatopathology as a comparison. Residents receive extensive dermatopathology education and testing, yet many practicing dermatologists ultimately rely on dermatopathologists to interpret specimens. Skin examinations, meanwhile, are performed routinely by dermatologists and advanced practice clinicians.

“We have to educate on dermoscopy. Dermoscopy has to become a requirement in curriculums,” Christopher said.

He argued that residency programs should provide dermoscopy education with an intensity comparable to dermatopathology so clinicians enter practice equipped to identify subtle malignant lesions.

That education also has to extend beyond recognizing a handful of classic patterns. Clinicians should understand polarized and nonpolarized dermoscopy, dynamic dermoscopy, UV fluorescence dermoscopy, and the significance of structures visualized within a lesion, Christopher said.

Reducing Anchoring and Age Bias

Technical training is only part of the equation. Christopher also emphasized the role of cognitive bias in missed diagnoses, particularly when a patient's age or an initially reassuring feature pushes the clinician toward a benign diagnosis.

A lesion that appears consistent with a dermatofibroma, actinic keratosis, lentigo, or seborrheic keratosis can create an anchor that influences how subsequent findings are interpreted.

One strategy for countering this tendency is to deliberately evaluate the entire lesion rather than allowing a single recognizable feature to determine the diagnosis. Christopher highlighted the inverse approach to dermoscopy as one framework that can help clinicians systematically evaluate structures and reconsider lesions that do not fully satisfy criteria for an assumed benign diagnosis.

The underlying principle is simple: Clinicians should not stop evaluating a lesion after finding the first feature that appears to support the expected diagnosis.

Clinic Structure Can Affect Diagnostic Accuracy

Reducing diagnostic error may also require changes to clinic workflow.

Full-body skin examinations demand sustained concentration, Christopher said, and attempting to simultaneously address unrelated concerns such as hair loss, psoriasis, or eczema can distract from careful lesion assessment.

In his own practice, he separates full-body examinations from visits addressing other dermatologic concerns and limits how many skin examinations are scheduled consecutively. He also avoids rigidly applying the same examination time to every patient.

A patient with relatively few lesions may require substantially less time than someone with hundreds of nevi, extensive tattoos, or dense hair, for example.

“You can't rush through them,” Christopher said.

For clinicians working within high-volume settings, the broader takeaway is that examination quality should determine workflow—not the reverse.

Dermoscopy Beyond Pigmented Lesions

Dermoscopy is also valuable when evaluating lesions that might otherwise be dismissed as inflammatory or benign.

Through inflammoscopy, clinicians can assess vascular morphology and other structures associated with conditions such as psoriasis and lichen planus. At the same time, dermoscopy can reveal features suggesting malignancy within a pink or scaly lesion that might initially resemble an inflammatory process.

This distinction becomes particularly important when widespread inflammation complicates a full-body examination. Christopher noted that severe eczema or psoriasis can obscure the skin enough that a complete examination may need to be deferred until inflammation improves.

Scale itself should not reassure clinicians that a lesion is benign, however. Malignancies can also present with scale, reinforcing the need to assess suspicious lesions rather than relying on their overall clinical appearance.

Expanding Dermoscopy Education Across Skin Tones

Block also raised another educational challenge: the limited representation of diverse skin tones in dermoscopy training materials.

Christopher agreed that clinicians need greater exposure to the range of normal and abnormal dermoscopic patterns seen across skin tones. Pigment patterns within nevi can differ, making education about expected findings essential for distinguishing normal variation from concerning structures.

The problem extends to existing textbooks and atlases, many of which contain relatively limited image collections, Christopher said.

Larger, more diverse image repositories could therefore serve multiple purposes: improving clinician education while also providing stronger datasets for emerging artificial intelligence tools.

AI Depends on the Quality of Its Training Data

Although Christopher sees potential for AI-assisted dermoscopy, he cautioned against assuming that a large-sounding training dataset is necessarily comprehensive.

The variability among melanocytic lesions is enormous, he explained, meaning algorithms must account for far more than a simple distinction between organized and disorganized patterns. Understanding the source, diversity, and quality of images used to train a model is therefore critical when evaluating its potential clinical utility.

AI may ultimately have particular value in settings where dermatology access is limited, but Christopher argued that technology should complement—not replace—clinician expertise.

Education remains the most practical starting point.

He pointed to models in Australia and New Zealand, where general practitioners may receive substantial training in skin cancer detection, as an example of how expanding dermoscopy competency beyond dermatologists could potentially support earlier recognition in areas with limited specialist access.

Moving Dermoscopy Toward a Baseline Standard

Making full-body dermoscopic evaluation routine will require overcoming both educational and philosophical barriers.

Debate continues over the value of broader skin cancer screening and its effect on melanoma mortality. But Christopher argued that the discussion should also account for how examinations are performed. Having a diagnostic tool is not enough if clinicians are not consistently trained to use and interpret it.

The unaided eye cannot reveal every structure that becomes visible under dermoscopy, he emphasized. Very small lesions that appear unremarkable clinically can look substantially different once examined with a dermatoscope.

For Christopher, that limitation is precisely why dermoscopy education matters.

“We have to remove our bias that we know everything,” he said. “This device allows me to appreciate structures that are within the skin that I can't see.”

Ultimately, the goal is not simply to perform more examinations. It is to perform better ones—using appropriate tools, sufficient time, and training to recognize melanoma before a patient notices a changing lesion themselves.

References

1. Vestergaard ME, Macaskill P, Holt PE, Menzies SW. Dermoscopy 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 PubMed
2. 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 Dermatol. 2013;68(6):1000-1005. doi:10.1016/j.jaad.2012.11.032 PubMed