Summary of "Teledermatologijos mokymai"

Purpose and audience

Training for family doctors and primary‑care clinicians on recognition, assessment and teledermatology management of skin tumors.
Prepared by dermatovenerologists from Vilnius University Hospital Santaros Clinics and Lithuanian University of Health Sciences Kaunas Clinics; presented by Tadas Raudonis.

Big‑picture messages

Skin cancer incidence is increasing (aging population, greater UV exposure). Early detection dramatically improves outcomes (example: a German screening pilot showed major mortality reduction).
Family doctors play a central role: most patients with melanoma first see their family doctor. Good history‑taking, full‑body skin exams, patient education and teledermatology improve early diagnosis and access to specialist advice.
Dermatoscopy is a core, non‑invasive tool that substantially improves diagnostic accuracy for both pigmented and non‑pigmented lesions when used correctly.

Epidemiology and clinical importance

Skin cancer comprises a large portion of oncologic diagnoses worldwide; incidence varies by region (very high in Australia/New Zealand; lower in Lithuania).
Non‑melanoma skin cancers (basal cell carcinoma [BCC], squamous cell carcinoma [SCC]) are the most common. Melanoma is less common but has high mortality when advanced.
Early‑stage melanoma has excellent 5‑year survival (~99%); advanced disease survival drops markedly. This underlines the importance of early detection and patient self‑check education.

Patient self‑examination — step‑by‑step

Preparation

Choose a bright, quiet place with a full‑length mirror and a hand mirror (use a comb to part hair).

Examination sequence

Face, ears, scalp (part hair and inspect behind ears).
Neck and décolleté.
Shoulders, chest, abdomen (women: under breasts), body folds, navel.
Arms: shoulders → upper arms → forearms → elbow creases → palms, between fingers, nails.
Back and buttocks (use two mirrors to view the back).
Legs while seated: thighs, calves, tops and soles of feet, between toes.
Genital and perianal area using a hand mirror.

What to look for

New or changing lesions, bleeding, pain, numbness, unusual color or shape.
Encourage monthly checks for high‑risk patients.

When a lesion is suspicious

Sudden appearance in an adult, rapid change in size/shape/color/texture, bleeding or non‑healing.
Ugly duckling rule: a lesion that looks different from a patient’s other nevi.

Key mnemonic (ABCDE)

Asymmetry, Border irregularity, Color variegation (>2–3 colors), Diameter >6 mm, Evolution/change.

Sites of special concern: palms/soles, nails, mucosa, scalp, chronically sun‑exposed areas, and tattooed skin if changes occur.

Role and benefits of teledermatology

Provides faster diagnostic advice, improves early detection accuracy, increases access in underserved regions and reduces waiting times.
System‑level benefits include economic gains and improved patient quality of life.
For teleconsultation, supply high‑quality images plus a complete, structured history (see History section).

Dermatoscopy — principles and practical requirements

What it visualizes

Dermatoscopy reveals epidermal and superficial dermal structures and capillaries not seen by the naked eye; it increases diagnostic specificity and sensitivity when used by experienced clinicians.

Types of dermatoscopes

Handheld: most common; often requires smartphone/tablet adapters to digitize images.
Mobile digital dermatoscopes: pair directly with a phone for immediate digital images.
Stationary/desktop digital systems: high‑quality imaging for documentation; expensive and space‑consuming.

Technical recommendations

Minimum ~10× magnification and a wide field of view (preferably ≥3 cm).
Integrated LED lighting; both polarized and non‑polarized modes.
Integrated ruler for measurements and compatibility with mobile devices/adapters.
Rechargeable high‑capacity battery and disinfectant‑resistant design.

Polarized vs unpolarized light

Unpolarized: better for superficial/epidermal structures.
Polarized: visualizes deeper dermal structures; modern polarized devices often eliminate the need for immersion fluid.

Immersion

Immersion liquids (alcohol, water, spray disinfectant) reduce surface reflection and can improve visualization of deeper structures; often unnecessary with polarized dermatoscopes unless the lesion is very dry/scaly.

Photography and image consistency

Photograph lesions with consistent orientation (same vertical axis) across visits.
Use a dermatoscope ruler or millimeter ruler in macroscopic photos for size documentation.
Recommended mobile camera: ≥12 MP with manual focus capability.
Use device‑specific or universal adapters; center the adapter over the main camera and align dermatoscope optic before coupling.

How to use a dermatoscope — practical workflow

Disinfect contact surface of the dermatoscope (do not spray disinfectant directly on the device). Clean patient skin (remove makeup/creams).
Use both polarized and unpolarized modes for contact dermatoscopy when possible.
Ensure the whole lesion fits within the dermatoscope field; hold steadily but avoid excessive pressure to preserve vascular visibility.
Focus using the dermatoscope focus wheel; adjust further for photography.
Measure the lesion: record the longest axis and perpendicular axis when possible; for very small/irregular lesions record maximum length. Include a ruler in macroscopic photos or use the integrated dermatoscope ruler.

Dermatoscopic patterns and diagnostic pointers (condensed)

Pigment network

Regular honeycomb network → melanocytic lesions / benign nevi.
Irregular, thick, interrupted network → dysplastic nevus or melanoma (refer/biopsy).
Absence of a pigment network → likely non‑melanocytic lesion.

Melanocytic lesions (typical clues)

Junctional nevi: flat with regular pigment network.
Compound/mixed nevi: central raised area with peripheral network.
Dermal nevi: raised, skin‑colored to lightly pigmented, may show pigment globules.
Blue nevus: structureless dark blue/gray/black area (deep dermal pigment).
Dysplastic nevus: irregular network, asymmetry, multiple colors → monitor or refer.

Benign non‑melanocytic lesions

Seborrheic keratosis: horn/keratin cysts, looped vessels, hyperkeratosis.
Soft fibroma (skin tag): homogeneous skin‑colored structure.
Dermatofibroma: central dimpling on lateral compression; central hypopigmentation with peripheral pigment network.
Hemangioma: red/pink lacunae or dots with whitish septa.
Thrombosed angioma: red‑black diffuse pigment from thrombosed capillaries.
Epidermoid cysts, lipomas, sebaceous hyperplasia, syringomas: usually benign; remove only for symptoms/aesthetics.

Malignant / premalignant lesions

Basal cell carcinoma (BCC): arborizing vessels, leaf‑like structures, blue‑gray ovoid nests/globules, ulceration, shiny white lines/areas.
Actinic keratosis: scaly, rough papules/plaques on sun‑exposed skin; dermatoscopy shows a red background with fine scaling and white follicular openings (“strawberry” appearance).
Squamous cell carcinoma (SCC) / Bowen disease: erythematous scaly plaques with polymorphous vessels (glomerular, hairpin, tortuous) and hemorrhagic areas. SCC can metastasize (~up to 5%).
Melanoma: asymmetry, irregular borders, multiple colors (brown/black/gray/blue/red/white), irregular pigment network, structureless areas, regression (white/blue‑gray), pseudopods/radial projections and chaotic/mixed patterns. Fast identification and excision are critical.

History‑taking and documentation for referrals / teledermatology

Key questions to record

When was the lesion first noticed? (new adult lesions are suspicious)
Has it changed (size, color, shape, texture, elevation)? How fast?
Symptoms: pain, itching, burning, numbness, bleeding, ulceration, discharge.
Previous removal or recurrence of the lesion.
Personal/family history of skin cancer (first‑degree relative melanoma especially relevant) and other cancers (some genetic links).
UV exposure history: sun habits, tanning bed use, history of sunburns.
Immune status: organ transplant, immunosuppressive therapy.
Skin phototype and number of nevi (>50 raises risk).

Photography and measurements

Provide macro photo with ruler + dermatoscopic images.
Record measured lesion dimensions (longest axis ± perpendicular) and a full clinical description.

Full‑body skin exam technique — practical sequence

Preparation

Good lighting, private space, chaperone if needed, comb to part hair.

Systematic sequence

Scalp and hairline (part hair; inspect behind ears).
Face, ears, eyelids, nostrils, lips (inspect mucosa and lower lip).
Neck and décolleté (front and sides).
Shoulders, chest, abdomen (women: under breasts), navel.
Arms: shoulders → upper arms → forearms → elbow bends → palms and nails.
Back and buttocks (use mirrors or have patient turn).
Lower extremities: thighs → calves → front of legs → feet (tops, soles, between toes), nails.
Genital and perianal examination as indicated.

Palpate lesions when indicated (e.g., dermatofibroma central dimpling).

When to refer to dermatology and biopsy recommendations

Urgent referral if lesion meets ABCDE criteria, is an ugly duckling, rapidly changing, bleeding/non‑healing, or clinically consistent with invasive SCC, aggressive BCC, or melanoma.
Use teledermatology when specialist access is limited — include quality photos and full history.
Indications for biopsy/excisional biopsy: indeterminate or suspicious lesions, especially when melanoma cannot be excluded.

Illustrative clinical cases — key takeaways

BCC: shiny white lines, blue‑gray dots, arborizing/tortuous vessels, erosion/serohemorrhagic crust.
SCC: erosion, whitish structureless areas, irregular linear vessels.
Amelanotic melanoma: scaly surface with chaotic vascular pattern without pigment (“vascular chaos”).
Tattooed skin: ink can obscure features — inspect carefully.
Seborrheic keratosis: horn cysts and peripheral looped capillaries — benign pattern.

Practical tips and rules emphasized

Maintain consistent photo orientation and include a scale on images.
Use both polarized and non‑polarized modes where available.
Avoid spraying disinfectant directly onto dermatoscope optics; clean the patient’s skin before contact dermatoscopy.
Use a standardized history and image submission format for teledermatology to improve triage and diagnostic accuracy.

Speakers and sources

Presenter: Tadas Raudonis.
Contributors: dermatovenerologist teams from Vilnius University Hospital Santaros Clinics and Lithuanian University of Health Sciences Kaunas Clinics.
Reference: a German pilot skin‑cancer screening project (“Green”) was cited.
Dermatoscope models mentioned: Hine Delta 30; DermLite DL4 / DL5.
Additional literature sources were noted at the end of the video (not individually listed in subtitles).

Category

Educational

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