The Utility of Clinical Photographs in Dermatopathologic Diagnosis: A Survey Study FREE

Dermatopathologists receive skin biopsy specimens accompanied by requisition slips that help direct their diagnoses. Owing to busy clinician’s time constraints and the increasing frequency with which the paperwork is completed by physician extenders rather than physicians, the requisition slips often do not contain adequate information. In some cases, this makes diagnosis more challenging.

Prior reports have emphasized the importance of clinicopathologic correlation and the usefulness of clinical photography as an aid in diagnosis.^1- 2 The present study examines (1) how often photographs are currently being used as an aid in dermatopathologic diagnosis, (2) in which situations they are most likely to be helpful, and (3) whether dermatopathologists want to receive photographs more frequently.

After approval from the institutional review board at Eastern Virginia Medical School, Norfolk, and the American Society of Dermatopathology (ASDP) board of directors, an anonymous, voluntary, Web-based survey was e-mailed to all board-certified dermatopathologist members of the ASDP. In November 2009, the e-mail invitation was sent to all 816 members who provided their e-mail addresses to the ASDP; 34 of the e-mail addresses were considered invalid because an error message was received in response. The survey remained available for responses for 30 days, and a reminder was sent during the final week. In addition to multiple choice answers, respondents were given the opportunity to write additional comments and feedback on the topic. Statistical analysis was performed using SAS computer software, version 9.2 (SAS Institute Inc, Cary, NC).

There were 135 complete responses and 13 partial responses from all regions of the United States from both dermatology- and pathology-trained individuals. At least 2 respondents had completed both dermatology and pathology residencies. There were 4 international responses. Current frequency of photography usage is summarized in the Table. Analysis with the Cochran-Mantel-Haenszel statistic revealed no significant difference in frequency of use among geographic regions. Ninety-four percent of dermatopathologists stated that they would like to receive photographs more frequently.

More respondents stated that clinical photography is beneficial in the evaluation of inflammatory skin diseases (92%) than in pigmented lesions (73%) or nonmelanocytic tumors and growths (56%). By Fisher exact test, we found no significant difference between pathology- and dermatology-trained dermatopathologists with regards to finding clinical photography useful in any category. Ninety-one percent of respondents stated that they were able to provide a more specific diagnosis with the aid of clinical photographs. For pigmented lesions, respondents stated that photography and history with measurements were helpful when only a portion of the lesion was biopsied. Otherwise, sampling error might lead to a misdiagnosis of melanoma. One respondent found photographs useful in reporting margins in complex surgical cases.

The most preferred methods of photograph delivery included printed-out photographs (54%) and encrypted e-mail (50%) followed by posting on a secure Web site (21%) and images on compact disc (10%). In addition, several respondents suggested integration into electronic medical records when available.

Respondents were also given the opportunity to write open-ended comments. Several dermatopathologists stated that clinical photographs are particularly useful when the specimen is submitted by a nondermatologist who provides a limited history and differential diagnosis. A potential drawback to photography mentioned is the time and cost that it takes for clinicians to take the photograph and send it to the dermatopathologist. In addition, photographs provided in a cumbersome format (compact disk or flash drive) may slow down sign-out for the dermatopathologist; a printed-out photograph attached to the requisition slip was the most preferred method of delivery for this reason. Furthermore, several people emphasized that clinical photographs should not replace a good history.

Limitations of this study include an inability for respondents to state that they were trained in both pathology and dermatology residencies prior to obtaining a dermatopathology fellowship. Two respondents included this information in the comment section. In addition, physicians who felt strongly about the beneficial use of clinical photography might have been more likely to respond to the survey, thus creating response bias and overestimating the beneficial effect of photography.

Overall, this survey study revealed that dermatopathologists find clinical photography most beneficial in the diagnosis of inflammatory skin diseases, and they would like to receive photographs more frequently. They prefer a convenient method of delivery, most commonly a printed-out photograph attached to the requisition slip.

Correspondence: Dr Mohr, Department of Dermatology, Eastern Virginia Medical School, 721 Fairfax Ave, Ste 200, Norfolk, VA 23507 (melinda.mohr@gmail.com).

Accepted for Publication: June 4, 2010.

Author Contributions: All authors had full access to all of the data in the report and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Mohr and Hood. Acquisition of data: Mohr. Analysis and interpretation of data: Mohr, Indika, and Hood. Drafting of the manuscript: Mohr and Indika. Critical revision of the manuscript for important intellectual content: Hood. Statistical analysis: Indika. Study supervision: Hood.

Financial Disclosure: None reported.

Additional Contributions: We thank the members of the ASDP who participated in this study and the Epidemiology and Biostatistics Core at Eastern Virginia Medical School, Norfolk, and Old Dominion University, Norfolk, for assisting with statistical analysis.