Bij de beoordeling van een patiŽnt met een dermatologisch probleem dient de gehele huid geÔnspecteerd te worden; bevindingen bij 483 patiŽnten.

 

Tijdens de opleiding tot dermatoloog kregen arts-assistenten te horen dat een patiŽnt met een huidziekte altijd geheel moet worden nagekeken. In de loop van de tijd is daar langzamerhand de klad in gekomen en wordt bij nieuwe patiŽnten lang niet altijd de gehele huid onderzocht.

Het doel van de studie, die leidde tot het schrijven van dit artikel, was, om uit te zoeken of de totale inspectie van de huid, bij hen die voor het eerst op het spreekuur kwamen, tot meer diagnoses van kwaadaardige huidziekten zou leiden dan wanneer de huid niet in zijn totaliteit zou zijn onderzocht. Bij 483 patiŽnten, die voor het eerst op de bewuste Engelse polikliniek dermatologie werden gezien, werd de huid totaal geÔnspecteerd, waarbij naast de klacht waarvoor men gekomen was, de volgende zaken aan het licht kwamen: Er werden 3 melanomen (zeer kwaadaardige moedervlekken) ontdekt, waarvan er 2 al in de diepte waren gegroeid en waarvan er 1 nog zeer oppervlakkig was gelegen.
Zestien patiŽnten hadden een basaalcelcarcinoom dat niet gevonden zou zijn als er alleen aan de primaire klacht aandacht zou zijn besteed.
DrieŽndertig patiŽnten hadden actinische keratosen (zonlicht beschadiging die kan uitgroeien tot huidkanker), of zelfs al een beginnend plaveiselcelcarcinoom. Eenentwintig patiŽnten hadden een verdachte plek die bij nader onderzoek niet kwaadaardig bleek te zijn en negen patiŽnten bleken een onrustige moedervlek (dysplastische naevus) te hebben.
Bij drieŽnzeventig patiŽnten werd een andere, goedaardige, huidaandoening gevonden waarvoor wel een behandeling gegeven werd, dan wel dat er tot verder onderzoek moest worden geadviseerd.

Conclusie: Tijdens de negen maanden dat deze studie duurde werden bij drie personen melanomen gevonden die niet gevonden zouden zijn als er geen totale inspectie van de huid was geweest. Melanomen leiden, als zij niet chirurgisch verwijderd worden, tot de dood. Bij zestien personen werd een basaalcelcarcinoom gevonden, dit is weliswaar geen dodelijke vorm van huidkanker, maar bij te lange doorgroei kunnen er zeer vervelende situaties ontstaan. Deze studie bevestigt volgens de auteurs dat bij onderzoek door de dermatoloog van de totale huid er nogal wat narigheid kan worden voorkomen. Commentaar van de recensent: het zou ook toeval kunnen zijn dat er zoveel afwijkingen gevonden werden bij dit onderzoek. Het zou een goede zaak zijn als een dergelijke studie op meer plaatsen zou worden herhaald.
Tekst: Dr. D. de Hoop.

Engelse tekst:

1. B. Moran,
2. I. McDonald,
3. D. Wall,
4. S.J. O’Shea,
5. C. Ryan,
6. A.J. Ryan,
7. B. Kirby
Article first published online: 29 SEP 2011
DOI: 10.1111/j.1365-2133.2011.10483.x
© 2011 The Authors. BJD © 2011 British Association of Dermatologists
Issue

Summary

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 (January–September 2009). All patients were examined by the same consultant dermatologist. Data were collected on patients’ sex, age, presenting complaint and findings on complete skin examination.

Results

Two nodular malignant melanomas with mean Breslow thickness of 0•6 mm (0•4%) and one melanoma in situ were identified at sites distant from the patient’s presenting complaint. Sixteen patients (3•3%) had a basal cell carcinoma that would not have been discovered if the presenting lesion alone had been examined. Thirty-three patients (6•8%) had actinic keratoses or squamous cell carcinoma in situ and nine (1•9%) had dysplastic naevi. A further 21 patients (4•3%) had a suspicious lesion biopsied or excised with subsequent benign histology. Seventy-three patients (15•1%) had other benign dermatological diagnoses requiring treatment or investigation.

Conclusions

In a 9-month period, in a sample of 483 new patients, three patients (0•6%) had potentially lethal skin malignancies identified that would not have been diagnosed without a complete skin examination. Sixteen (3•3%) patients had basal cell carcinomas that would have been missed without complete skin examination. This study confirms 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 inflammatory 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 first 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 findings. 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 18•6 and 46•7 per 100 000 population, respectively).

In a prospective study of 1106 patients in Pennsylvania in 1986, Lookingbill6 reported that 1•8% of patients had an incidental basal cell carcinoma and 0•1% 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 (2•8%) had an incidental nonmelanoma skin cancer, three had lentigo maligna (0•4%) and one patient (0•1%) 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 (January–September 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.).

Seventeen patients (3•4%) did not undergo complete skin examination. Most of these patients were female (n = 13; 76%). The mean age was 48•1 years (range 15–92). 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 benefit.

Four hundred and eighty-three patients (96•6%) underwent complete skin examination (Table 1). The mean age was 49 years (range 15–94), and 190 (39•3%) were male. Nearly one-third of patients (n = 155; 32•1%) had dermatological disease separate from their presenting complaint.

Table 1. Baseline patient  characteristics and findings of complete skin examination (CSE)

1. BCC, basal cell carcinoma; SCCIS, squamous cell carcinoma in situ; AK, actinic keratosis.
All patients undergoing CSE (n = 483)   49•0 (15–94)   190 (39•3) 
Normal CSE (n = 328)   46•9 (15–94)   117 (35•7)
Melanoma (n = 2) and melanoma in situ (n = 1)   63.0 (38–79)   2 (66.7) 
BCC (n = 16)   68•5 (48–86)   10 (62.5) 
SCCIS/AK (n = 33)   73•3 (47–90)   16 (48.5) 
Dysplastic naevus (n = 9)  

44•2 (26–75)

  7 (77.8) 
Biopsy with normal histology (n = 21)   50•2 (30–84)   7 (33.3) 
Other benign diagnosis (n = 73)   43•1 (16–86)  

31 (42.5)

Patients not examined (n = 17)   48•1 (15–92)   4 (23.5) 

There were two nodular malignant melanomas (0•4%; mean Breslow thickness 0•6 mm) and one melanoma in situ identified at sites distant from the patient’s presenting complaint of which the patients were unaware. The mean age of these patients was 63 years (range 38–79). Two of the patients were male. One of these male patients had a past history of melanoma. A further nine patients (1•9%) 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 (3•3%) had a basal cell carcinoma discovered that would not have been diagnosed without a complete skin examination. The mean age was 68•5 years (range 48–86); 10 (62%) were male. All cutaneous malignancy diagnoses were confirmed by histological analysis.

Thirty-three patients (6•8%) had actinic keratoses or squamous cell carcinomas in situ that required treatment. The mean age was 73•3 years (range 47–90); 16 (48%) were male. A further 21 patients (4•3%) 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 (15•1%) 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 findings are taken from patients attending general dermatology clinics who have been referred from general practitioners or nondermatologist hospital consultants with a variety of inflammatory, benign and malignant dermatological conditions. The mean age of patients undergoing complete skin examination was 49 years, with a wide range (15–94). Although this group may not be a sample of the general population, it is not a particularly ‘high-risk’ group either. We were surprised that 19 patients (3•9%) 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 figure is higher than that reported by Lookingbill6 in 1988 (2•0% 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 studies suggest that screening for skin cancer is beneficial 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 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 (6•8%) 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 (1•9%) patients had a dysplastic naevus excised. The findings 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 (96•6%) 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 confirm previous dogma and strongly suggest that every dermatology patient should have a complete skin examination at least on their first visit.

What’s 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.

What does this study add?

This prospective study documents all diagnoses discovered from  routine complete skin examination in a fair-skinned population.
Three patients (0•6%) had malignant melanomas and 16 (3•3%) had  basal cell carcinomas that would have been missed without complete skin examination. These figures 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. 

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