Teaching Benign Skin Lesions as a Strategy to Improve the Triage Amalgamated Dermoscopic Algorithm (TADA)

Elizabeth V. Seiverling, MD; Hadjh T. Ahrns, MD; Amrit Greene, MD; Melissa Butt, MPH; Oriol Yélamos, MD; Stephen W. Dusza, DrPH; Ashfaq A. Marghoob, MD


J Am Board Fam Med. 2019;32(1):96-102. 

In This Article

Abstract and Introduction


Introduction: Dermoscopy aids family physicians (FPs) in skin cancer detection. The triage amalgamated dermoscopic algorithm (TADA) was created to simplify the dermoscopic evaluation of a skin growth. The purpose of this image-based study was to evaluate the effect of teaching the clinical and dermoscopic features of benign skin lesions on the diagnostic accuracy of skin cancer identification using TADA. We also sought to determine the best method to teach benign neoplasms.

Methods: In this cross-sectional study of an educational intervention, FPs participated in dermoscopy training. Participants were divided into 3 groups for teaching of common benign neoplasms (dermatofibroma, angioma, and seborrheic keratosis/lentigo): didactic + interactive, didactic + heuristic, and didactic. For each group, the benign teaching was followed by skin cancer identification training with TADA. All participants took a 30 image pre-test and 30 image post-test.

Results: Fifty-nine participants completed the study. The mean preintervention score (out of 30 correct responses) was 17.9 (SD, 4.5) and increased to 23.5 (SD, 3.0) on the postintervention evaluation (P < .001). Sensitivity for skin cancer increased from 62.5% to 88.1% following the intervention. Postintervention specificity for skin cancer was 87.8%. Sensitivity and specificity increased following the intervention for all 3 types of benign neoplasms. Diagnostic accuracy was not impacted by the method of benign teaching.

Conclusion: Short dermoscopy training sessions with dedicated time for benign growths followed by TADA training for malignant growths are an effective means of teaching FPs dermoscopy and result in a high sensitivity and specificity for the identification of benign and malignant skin neoplasms.


Current estimates predict that 1 in 5 Americans will develop skin cancer in their lifetime.[1] Although melanoma is the deadliest form of skin cancer, when found in its early stages, cure rates reach nearly 100%.[1] One of the greatest opportunities for early detection of skin cancer resides within the hands of family physicians (FPs), who see patients that may not otherwise be regularly followed for total body skin examination by a dermatologist. However, studies have shown that FPs desire better training in dermatology and triaging cutaneous lesions.[2,3]

Dermoscopy is a noninvasive, in vivo, technique that uses a handheld instrument (dermatoscope), which uses polarized light to facilitate visualization of subsurface skin structures (epidermis, dermo-epidermal junction, and papillary dermis) that are otherwise not visible. Dermoscopy has vastly improved the diagnostic accuracy of the observer in the detection of cutaneous malignancies.[4,5]

It is, therefore, a valuable tool that can aid FPs in the detection of skin cancer. However, few dermoscopic algorithms were created for this target population of physicians. To address this issue, we previously described a dermoscopic algorithm known as triage amalgamated dermoscopic algorithm (TADA).[6] TADA requires minimal requisite knowledge of dermoscopy and is designed to facilitate triage of suspect lesions for monitoring, biopsy/referral, or reassurance. In a pilot, TADA was taught to a group of physicians (64 dermatologists, 19 FPs, and 22 other primary care providers) attending a dermoscopy course and showed good sensitivity and specificity for malignant skin lesions (94.8% and 72.3%, respectively).[7] Although no sensitivity differences were observed among specialists, specificity was higher among dermatologists (79% vs 72%, P = .008). In addition, there were no differences in sensitivity or specificity depending on the years of dermoscopy experience.[7]

The difference in specificity may be due to a better knowledge of the clinical features of benign skin growths among dermatologists. Thus, considering the majority of skin lesions that are evaluated in the clinical setting are benign lesions, we hypothesized that teaching the clinical and the dermoscopic features of the commonest benign lesions (dermatofibroma, angioma, and seborrheic keratosis/lentigo) would improve the specificity of the algorithm and, therefore, would improve the diagnostic accuracy of TADA when used by FPs. The objectives of our study were to (1) evaluate the effect of teaching the clinical and dermoscopic features of benign skin lesions on the sensitivity and specificity of TADA; (2) determine which is the best method to teach benign skin lesions: heuristic teaching, didactic teaching, or interactive cases; and (3) confirm the ability of FPs to use TADA to identify dermoscopic images of skin cancer (prior pilot study only included 19 FPs).