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BJD

CONCISE COMMUNICATION British Journal of Dermatology

Complete skin examination is essential in the assessment of dermatology patients: ndings from 483 patients
B. Moran, I. McDonald, D. Wall, S.J. OShea, C. Ryan, A.J. Ryan and B. Kirby
Department of Dermatology, St Vincents University Hospital, Elm Park, Dublin 4, Ireland

Summary
Correspondence
Benvon Moran. E-mail: benvonmoran@gmail.com

Accepted for publication


15 June 2011

Funding sources
None.

Conicts of interest
None declared. DOI 10.1111/j.1365-2133.2011.10483.x

Background Dermatological teaching has traditionally stressed that complete skin examination is essential in the assessment of patients with potential skin disease. Objectives To determine whether complete skin examination results in increased diagnoses of skin malignancies that would not have been discovered otherwise. Methods New patients (n = 483) attending a dermatology clinic in a university teaching hospital and private dermatology practice had a complete skin examination, as is our normal practice. These patients were seen over a 9-month period (JanuarySeptember 2009). All patients were examined by the same consultant dermatologist. Data were collected on patients sex, age, presenting complaint and ndings on complete skin examination. Results Two nodular malignant melanomas with mean Breslow thickness of 06 mm (04%) and one melanoma in situ were identied at sites distant from the patients presenting complaint. Sixteen patients (33%) had a basal cell carcinoma that would not have been discovered if the presenting lesion alone had been examined. Thirty-three patients (68%) had actinic keratoses or squamous cell carcinoma in situ and nine (19%) had dysplastic naevi. A further 21 patients (43%) had a suspicious lesion biopsied or excised with subsequent benign histology. Seventy-three patients (151%) had other benign dermatological diagnoses requiring treatment or investigation. Conclusions In a 9-month period, in a sample of 483 new patients, three patients (06%) had potentially lethal skin malignancies identied that would not have been diagnosed without a complete skin examination. Sixteen (33%) patients had basal cell carcinomas that would have been missed without complete skin examination. This study conrms the traditional teaching that complete skin examination has the potential to reduce morbidity and mortality from cutaneous malignancy.

Dermatologists have traditionally taught that a complete skin examination is important in aiding the diagnosis of both inammatory and lesional skin diseases and in screening for skin malignancies, particularly malignant melanoma.1 It has been our normal practice that patients are undressed to their underwear for a full skin assessment at least on their rst visit. There have been recent retrospective studies of malignant melanoma diagnoses by dermatologists, separate from the patients presenting complaint. In a retrospective study Kantor and Kantor2 studied all cases of melanoma diagnosed in a private practice in Florida over a 3-year period. They reported that over half of the 126 melanomas and melanomas in situ diagnosed were detected as a result of complete skin examination. These melanomas were thinner and more likely to be

in situ than melanomas that were the presenting complaint. A similar study by Cherian and Tait3 from Australia had comparable ndings. Sixty per cent of the melanomas diagnosed in this study were found incidentally on complete skin examination. These populations could be considered high risk due to the geographical location (the incidences of melanoma in 2007 in Florida4 and Australia5 were 186 and 467 per 100 000 population, respectively). In a prospective study of 1106 patients in Pennsylvania in 1986, Lookingbill6 reported that 18% of patients had an incidental basal cell carcinoma and 01% of patients had an incidental melanoma found after complete skin examination. A study from Illinois in 1991 reviewed the charts of 707 patients who underwent complete skin examination.7 Twenty patients (28%) had an incidental nonmelanoma skin cancer,
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Complete skin examination in the assessment of dermatology patients, B. Moran et al. 1125

three had lentigo maligna (04%) and one patient (01%) had an incidental invasive melanoma found. We sought to assess whether complete skin examination is a useful screening exercise in a temperate climate such as Ireland.

Materials and methods


Five hundred new referrals were seen in a general university hospital clinic and a private dermatology practice over a 9-month period (JanuarySeptember 2009). All patients were offered complete skin examination as part of our normal consultation practice. The results of this examination were recorded on a proforma, along with information on age, sex and presenting complaint. All patients were examined by the same consultant dermatologist (B.K.).

Results
Seventeen patients (34%) did not undergo complete skin examination. Most of these patients were female (n = 13; 76%). The mean age was 481 years (range 1592). Ten of these patients refused examination. Examination of the remaining seven patients was deemed inappropriate by the investigators as it was judged that the distress (physical or emotional) the examination would have caused outweighed the potential benet. Four hundred and eighty-three patients (966%) underwent complete skin examination (Table 1). The mean age was 49 years (range 1594), and 190 (393%) were male. Nearly one-third of patients (n = 155; 321%) had dermatological disease separate from their presenting complaint. There were two nodular malignant melanomas (04%; mean Breslow thickness 06 mm) and one melanoma in situ identied at sites distant from the patients presenting complaint of which the patients were unaware. The mean age of
Table 1 Baseline patient characteristics and ndings of complete skin examination (CSE) Mean Age years (range) All patients undergoing CSE (n = 483) Normal CSE (n = 328) Melanoma (n = 2) and melanoma in situ (n = 1) BCC (n = 16) SCCIS AK (n = 33) Dysplastic naevus (n = 9) Biopsy with normal histology (n = 21) Other benign diagnosis (n = 73) Patients not examined (n = 17) 490 (1594) 469 (1594) 63.0 (3879) 685 733 442 502 (4886) (4790) (2675) (3084)

these patients was 63 years (range 3879). Two of the patients were male. One of these male patients had a past history of melanoma. A further nine patients (19%) had clinically dysplastic naevi discovered on complete skin examination and subsequently excised. Histological analysis showed that three were moderately dysplastic and four were mildly dysplastic; in two lesions the degree of dysplasia was not reported. Sixteen patients (33%) had a basal cell carcinoma discovered that would not have been diagnosed without a complete skin examination. The mean age was 685 years (range 4886); 10 (62%) were male. All cutaneous malignancy diagnoses were conrmed by histological analysis. Thirty-three patients (68%) had actinic keratoses or squamous cell carcinomas in situ that required treatment. The mean age was 733 years (range 4790); 16 (48%) were male. A further 21 patients (43%) had lesions discovered on complete skin examination that, in the opinion of the consultant, warranted excision or biopsy. The histological analysis of these specimens revealed benign histology. Seventy-three patients (151%) had other benign dermatological conditions found that required treatment or further investigation. These included psoriasis, eczema, acne and dermatophyte infections.

Discussion
These results strongly support the traditional dogma that the gold standard for dermatological assessment includes a complete skin examination. These ndings are taken from patients attending general dermatology clinics who have been referred from general practitioners or nondermatologist hospital consultants with a variety of inammatory, benign and malignant dermatological conditions. The mean age of patients undergoing complete skin examination was 49 years, with a wide range (1594). Although this group may not be a sample of the general population, it is not a particularly highrisk group either. We were surprised that 19 patients (39%) had skin cancers, three of which had potentially lethal consequences that would have been missed in a 9-month period without complete skin examination. This gure is higher than that reported by Lookingbill6 in 1988 (20% of patients had an incidental cutaneous malignancy). Since then the incidence of skin cancer has increased precipitously, suggesting that complete skin examination is even more important now than when advocated by Lookingbill 23 years ago. We would argue that this and other studies6,7 suggest that screening for skin cancer is benecial in the population presenting to dermatology clinics. Skin cancer is the most commonly occurring neoplasm in caucasian populations. Most of these are nonmelanoma skin cancers which are generally not life threatening. The early detection of these cancers is still important, as treatment is generally simpler and less invasive than when detected at a later stage. Two malignant melanomas and one melanoma in situ would have been missed unless a complete skin examination had

Male, n (%) 190 (393) 117 (357) 2 (66.7) 10 16 7 7 (62.5) (48.5) (77.8) (33.3)

431 (1686) 481 (1592)

31 (42.5) 4 (23.5)

BCC, basal cell carcinoma; SCCIS, squamous cell carcinoma in situ; AK, actinic keratosis.

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been performed, with potentially serious complications for these patients. Early detection can help to identify thinner melanomas, which are well established to have a better prognosis. Thirty-three (68%) patients had a premalignant condition (actinic keratosis or squamous cell carcinoma in situ) that was treated, potentially preventing a nonmelanoma skin cancer occurring that would have required more aggressive management. Nine (19%) patients had a dysplastic naevus excised. The ndings of this study suggest that complete skin examination has the potential to reduce morbidity and mortality from cutaneous malignancy. The time taken to perform a complete skin examination is perhaps the reason that some dermatologists do not do this. We did not collect data on the time needed to perform a complete skin examination. Zalaudek et al.8 reported a median time of 70 s without dermoscopy in a pigmented lesion clinic. Hantirah et al.9 described a mean time of 6 min including dermoscopy or the use of other diagnostic tools in a general dermatology clinic. Both of these studies measured the time taken for examination after the patient had undressed. Our study suggests that complete skin examination is essential and that time and facilities should be available in National Health Service clinics to perform this important examination. Complete skin examination is a quick and risk-free procedure. The vast majority (966%) of our patients readily availed of complete skin examination when it was offered to them as part of our routine clinical practice. It is our opinion that these results conrm previous dogma and strongly suggest that every dermatology patient should have a complete skin examination at least on their rst visit.

What does this study add?


This prospective study documents all diagnoses discovered from routine complete skin examination in a fairskinned population. Three patients (06%) had malignant melanomas and 16 (33%) had basal cell carcinomas that would have been missed without complete skin examination. These gures are higher than those demonstrated in previous older prospective studies. This study provides evidence that this quick and easy procedure should be offered to all patients attending dermatology clinics, regardless of presenting complaint.

References
1 du Vivier A. Atlas of Clinical Dermatology, 3rd edn. Edinburgh: Churchill Livingstone, 2002: 2. 2 Kantor J, Kantor DE. Routine dermatologist-performed full-body skin examination and early melanoma detection. Arch Dermatol 2009; 145:8736. 3 Cherian P, Tait CP. Melanoma in private practice: do dermatologists make a difference? Australas J Dermatol 2009; 50:25760. 4 U.S. Cancer Statistics Working Group. United States Cancer Statistics: 19992007 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute, 2010. 5 AIHW 2010. Cancer in Australia 2010: An Overview. Cancer series no. 60. Cat. no. CAN 56. Canberra: AIHW. 6 Lookingbill DP. Yield from a complete skin examination. Findings in 1157 new dermatology patients. J Am Acad Dermatol 1988; 18:317. 7 Lee G, Massa MC, Welykyj S et al. Yield from total skin examination and effectiveness of skin cancer awareness program. Findings in 874 new dermatology patients. Cancer 1991; 67:2025. 8 Zalaudek I, Kittler H, Marghoob AA et al. Time required for a complete skin examination with and without dermoscopy: a prospective, randomized multicenter study. Arch Dermatol 2008; 144:50913. 9 Hantirah SA, Yentzer BA, Karve SJ et al. Estimating the time required for a complete skin examination. J Am Acad Dermatol 2010; 62:8868.

Whats already known about this topic?


Retrospective case series in high-risk populations have shown that complete skin examination increases the number of melanoma diagnoses. Complete skin examination can reveal incidental rashes or other diagnoses requiring investigation and treatment, as well as uncovering neoplasms.

2011 The Authors BJD 2011 British Association of Dermatologists 2011 165, pp11241126

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