Exploration of Dermoscopy use among Dermatology Residents in Riyadh, Saudi Arabia
Introduction: Dermoscopy is a non-invasive technology used to examine the skin's invisible microstructures in dermatological practice and is gaining prominence as a crucial technology Dermoscopy usage is an evidence-based practice that is used to increase the early detection of skin malignancies and it helps in distinguishing between various skin conditions including pigmented and non-pigmented skin malignancies Currently, the vast majority of worldwide guidelines for skin cancer recommend dermoscopy as a critical component. The use of dermoscopy is increasing worldwide, but to date, no study has documented the attitudes toward and use of dermoscopy among fut (Preprint)
Authors: Almeziny Abdullah , Almutairi Rahaf , Altamimi Amal , Alshehri Khloud , Almehaideb Latifah , Shadid Asem , Al Mashali Mohammed 
Published: July 2024

BACKGROUND

Dermoscopy is a non-invasive technology used to examine the skin's invisible microstructures in dermatological practice. It is an established technique for analyzing skin lesions that have been in use since the 17th century when Kohlhaus used a microscope to study nail matrix vessels. [1–3]. However, dermoscopy was not widely used until the 20th century, when Goldman created a portable microscope that could magnify up to ten times more than the naked eye [1–6]. Historically, dermoscopy has been used to diagnose pigmented lesions such as naevi, melanomas, and pigmented basal cell carcinomas [7]. Since the 1990s it has been used to diagnose other dermatological disorders, including infections such as scabies, inflammatory lesions, and hair and nail-fold alterations, and it is also used to track lesions’ progress or reactions to topical treatments such as imiquimod or 5-fluorouracil [8–11]. The evidence-based practice associated with dermoscopy use improves the diagnostic accuracy for skin cancer, reduces unnecessary biopsies of benign lesions, increases survival rates, and improves the early identification of skin malignancies [12–14]. A 2002 meta-analysis of 27 studies revealed that dermoscopy increases experienced physicians’ diagnostic accuracy for melanoma compared to unaided inspection [1]. Moreover, it helps distinguish between various kinds of pigmented and non-pigmented skin malignancies in vivo, and it is significant in differentiating between inflammatory and neoplastic lesions. Currently, the vast majority of worldwide guidelines for skin cancer recommend dermoscopy as a critical component of diagnosing and following up with patients facing an increased risk of this disease [15–20]. Dermoscopy is also increasingly accepted as a standard practice around the globe. Multiple studies have revealed that United States dermatologists use dermoscopy. Indeed, 48% of 3,238 American dermatologists surveyed in 2010 said they used dermoscopy [21]. Chamberlain’s study of dermoscopy revealed a 98% utilization rate use in Australia [22–23], while 95% of dermatologists in France use the practice [24]. However, no study has documented the attitudes toward and use of dermoscopy among future dermatologists in Saudi Arabia. In this study, dermoscopy prevalence among dermatology residents in Riyadh was assessed alongside information sources and elements that influence its use, such as residency levels and the frequency of dermoscopy diagnoses.

OBJECTIVE

to know the attitudes toward and use of dermoscopy among future dermatologists in Saudi Arabia.

METHODS

Methods and Materials
1.	Study design:
A cross-sectional study was conducted in Riyadh to determine the attitudes of dermatologists towards the dermoscopy. The convenience sampling technique was employed in this study to recruit the study participants. The questionnaire tool was distributed in January 2024 through email registered at the Saudi Commission for Health Specialist.
The inclusion criterion for this study was to be a registered dermatology residents in Saudi boards in Riyadh. Any participants who did not meet these inclusion criteria was excluded from this study.
2.	Questionnaire tool:
This study adapted and used a previously questionnaire tested and found valid and reliable by Forsea et al.,. The questionnaire was comprised of two sections. The first section collected information related to participants’ demographics (Gender, Age, residence level). The second section, the future dermatologists who took part were asked about their perspectives about the utility of dermoscopy, their use patterns, their training experiences, and their self-reported confidence in dermoscopy diagnosis.
3.	Ethical Approval
This study was approved by the institutional review board at Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia.

4.	Study Analysis
All research data were entered into a Microsoft Excel version 16.0 spread- sheet. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY). Descriptive statistics were used in the statistical analysis; relative frequencies (%) were used to present categorical variables. A 2-sided value of P < .05 was considered statistically significant.

RESULTS

A total of 63 dermatology residents in Riyadh, Saudi Arabia equivalent to an 87.5% response rate, completed the online questionnaire. More than half the participants (34; 54.0%) of participants were female, while the vast majority (53; 84.1%) were aged between 26 and 30 years, and a considerable proportion of the respondents (22; 34.9%) were working at the R4 residency level.More than half of the participants (34; 54.0%) owned a dermatoscopy, while a substantial number (23 participants; 36.5%) offered an average of 21–30 monthly clinics. Most participants (57; 90.5%) presented an average number of zero to five clinics per month where they saw patients with cancer (all types). More than half of the participants (36; 57.1%) had received dermoscopy training, and a considerable proportion (21 participants; 33.3%) had pursued academic activities provided by Dermatology Saudi Board Program outside of residency training. The majority of the participants (44; 69.8%) used dermoscopy, and a significant number of them had been inspired to do so by colleagues (12; 27.3%) and mentors (nine; 20.5%). The reported reasons for not using dermoscopy were its unavailability in an office (eight participants; 42.1%) and a lack of training (six participants; 31.6%). Half of the participants (22; 50.0%) of the participants reported having used dermatoscopy pictures in medical education, particularly in conferences lectures, ground rounds, and academic activities. Most of the participants (17; 38.6%) had completed a rotation at King Saud University Medical City in 2023. A considerable proportion of the participants (16; 36.4%) had used dermoscopy for two years; the majority used non-polarized immersion-contact dermoscopes (20 participants; 45.5%) or polarized-light dermoscopes (19 participants; 43.2%). Concerning their average practice, the majority (15 participants; 34.1%) reported using dermoscopy at least once per day. The ABCD rule ( Asymmetrical, Border, Color, Diameter) as reported to be the most common algorithm used by the majority of the participating dermatology residents (23; 52.3%) for the diagnosis of pigmented lesions.The findings revealed that the majority of the participants (22; 50.0%) used dermoscopy in < 10% of cases involving the examination of patients with inflammatory skin lesions. Moreover, a substantial majority (15 participants; 34.0%) used dermatoscopy in > 70% of cases involving the examination of pigmented skin tumors. Eleven participants (25.0%) used dermatoscopy for < 10% of their patients who were examined for non-pigmented skin tumors. Concerning the participants’ dermoscopy skills, the majority of them were somewhat confident in the assessment of non-pigmented skin tumors (26; 59.1%), inflammatory skin lesions (22; 50.0%), and pigmented skin tumors (19; 43.2%).The vast majority of the participants (41; 93.2%) reported that dermatoscopy was useful in diagnosing melanoma and following up on melanocytic lesions (39; 88.6%), diagnosing pigmented skin tumors (35; 79.5%), and diagnosing non-pigmented skin tumors (31; 70.5%). Concerning advantages, the majority of the participants agreed that dermatoscopy use increases confidence in their clinical diagnoses (30; 68.2%), reduces unnecessary biopsies or excisions (27; 61.4%), and improves record-keeping (25; 56.8%). Weighing in on performance, more than half of the participants (30; 68.2%) that dermoscopy use increases the number of melanomas detected compared to naked-eye examinations. Additionally, the majority of the participants (27; 61.4%) noted that the use of dermoscopy reduces the excision of benign lesions.The results established a statistically significant association between the participants’ ages, residency levels, and practice centers, with p-values <.05 (.003,* .001,* and .004*), respectively, as well as the use of dermoscopy among the participants. Additionally, this study established a statistically significant association between receiving dermoscopy training and confidence levels among dermatology residents with p-values < .05 (.002*). Furthermore, a statistically significant association between the type of training and the type of dermoscopy use was found, with p-values < .05 (.003*).The study aimed to assess dermoscopy use’s prevalence among dermatology residents in Riyadh, Saudi Arabia, and the need for dermoscopy training, as well as the practice’s benefits in diagnosing and treating skin diseases. The study’s sample was predominantly female. Moreover, the substantial majority of the participants operated at the R4 residence level and were aged between 26 and 30 years.
The study revealed that more than half of the surveyed dermatology residents owed a dreamscape, with a considerable majority seeing a significant number of patients with cancers of all types every month. Additionally, more than half of the participants had received dermoscopy training, and a considerable proportion were pursuing academic activities provided by the program outside of residency training. The study’s findings underscore the importance of dermoscopy use and the necessity of better dermoscopy training as an invaluable tool in the earlier recognition of different dermatological diseases [25], as well as future strategic planning and enhanced dermatoscopy training and practice in Saudi Arabia [26]. Our study verified that most of the participating dermatology residents used dermoscopy to manage their patient’s conditions, and they had received training on its use. A considerable proportion of the participants had used dermoscopy for two years, and the majority used the non-polarized immersion-contact and polarized-light dermoscopy types.
These findings are consistent with those of a study conducted by Freeman et al. in the United States, which revealed that dermatologists apply dreamscape in their daily routines to manage patients’ conditions and diagnose their patients [27]. Similarly, a study conducted by Jones et al. on dermatoscopy use as part of primary care in the United Kingdom found that dermatologists used dermatoscopy to manage their patients’ conditions daily at a rate of 98.5% [28]. According to the study findings, the majority of the respondents used dermoscopy, and a significant number of them had been inspired to do so by colleagues and mentors. However, some of the participants did not use dermoscopy due to dermoscopes’ unavailability in their offices and a lack of training. The findings align with those of the study conducted by Alqahtani and AlBukhari in Saudi Arabia, who found that the reason for avoiding dermatoscopy use among dermatologists was a lack of adequate education and training among residents [29]. Similarly, the findings were corroborated by Engasser and Warshaw’s study in the United States, which identified financial costs and a lack of training as the major reasons for avoiding dermatoscopy use among dermatologists [30].
The current study’s findings revealed that the majority of the participating dermatology residents used dermoscopy in < 10% of cases involving the examination of patients with inflammatory skin lesions, > 70% of cases involving the examination of patients for pigmented skin tumors, and < 10% of cases in which patients were examined for non-pigmented skin tumors. Additionally, the majority of the participants reported that dermatoscopy was useful in diagnosing melanoma, following up on melanocytic lesions, diagnosing pigmented skin tumors, and diagnosing non-pigmented skin tumors. These findings align with those of the study by Kuo et al., which involved dermatologists in Taiwan and noted that clinicians used dermatoscopy to examine pigmented and non-pigmented lesions [31]. The study found that the use of dermoscopy was associated with dermatologists’ increased confidence in their clinical diagnosis, that it reduced unnecessary biopsies or excisions, and that it improved record-keeping. Furthermore, the study revealed that dermoscopy use increased the number of melanomas detected compared to naked-eye examinations while also reducing the excisions of benign lesions.
The current study’s demographics are comparable to those of similar studies, with most of the participants being female. This predominance can be explained by the higher proportion of female dermatologists around the globe. In terms of age, the majority of the participating dermatology residents were aged 26–30 years. This finding implies that young dermatologists in Saudi Arabia are using the practice more often than older dermatologists. The findings align with those of the study by Blum et al. in Germany, which reported a higher rate of dermoscopy use among the younger generation [32]. This demonstrates the expansion of dermoscopy’s clinical uses and the younger generation’s willingness to adapt to new technologies in diagnosing and treating skin diseases.
The current study’s results may have been predisposed to some limitations. Cross-sectional research of this study’s nature encounters a limitation attributed to its inability to assess causal relationships. Additionally, given that the study involved the administration of an online questionnaire, it relied on the respondents’ accurately documenting their responses without the ability to confirm such accuracy, which may have contributed to bias

CONCLUSIONS

This study has revealed a considerably above-average level of dermatoscopy among use dermatology residents in Riyadh, Saudi Arabia. Dermatoscopy use is increasing among dermatologists, given the practice’s evidence-based advantages and benefits in the early detection and diagnosis of skin diseases. The participants’ ages, residency levels, and practice centers were found to be the main factors that affected dermoscopy use in Saudi Arabia. Finally, this study noted a willingness to improve one’s dermoscopy knowledge and skills, particularly among young dermatologists in Saudi Arabia.