The naked truth about total body skin examination: A lesson from Goldilocks and the Three Bears

By Lorraine L. Rosamilia, MD
Nov. 13, 2019
Vol. 1, No. 36

In my last 13 years of immersion in dermatology, I have often asked this simple yet elusive question of my superiors, my colleagues, and myself: Which patients need skin checks? As I peruse my clinical schedule, in which the majority of patients receive total-body skin examinations (TBSE), there lies a persistent impediment — there are patients who want to be seen "too often," some whom are seen "too little," and others who seem "just right." Akin to the fairy tale by Katharine Pyle, Goldilocks and the Three Bears (1918), the age-old dilemma of balance, namely that of time, risk-based resource management, and patient preference, shapes each clinical day. How do we curate a clinical schedule that targets patients who need our prevention and care the most?

If we deconstruct the sentence in question, its simplicity turns to confusion:

DO (Yes or no?)

I (Me? My family?)

NEED (Require or prefer? How often?)

A SKIN CHECK (Full body? Partial? By the dermatologist or primary care physician?)

Hence, I scrutinized the recent literature for guidance. Firstly, the TBSE is safe and well-received by patients, with negligible morbidity. (1) In 2016, the United States Preventative Services Task Force (USPSTF) reported that there is insufficient evidence to broadly recommend TBSEs. (2,3) However, the amassed USPSTF data were derived from all skin screenings, including those by non-dermatologists, and did not specify specialty-specific benefits or morbidity/mortality for high risk groups. USPSTF guidelines only target primary care trends, therefore, specialty societies such as our American Academy of Dermatology (AAD) issued subsequent statements outlining salient clarifications, namely that TBSE detects melanoma and keratinocyte carcinomas earlier than in patients who are not screened. (4,5) Unfortunately, randomized controlled trials to validate these observations are sparse, particularly due to the ethics of withholding screening from a prospective study group. To make sense of this dilemma, Johnson et al in 2017 outlined the best available survival data in concert with the USPSTF statement to arrive at judicious dermatology-specific skin cancer screening recommendations. They concluded that high risk patients, namely those with history of skin cancer, immunosuppression, indoor tanning, and/or many blistering sunburns, as well as several other genetic parameters, would benefit most from at least yearly TBSE. (6)

Regrettably, the techniques and reproducibility of TBSEs are also not standardized, though TBSE methods seem to have been endearingly apprenticed behind closed doors to generations of dermatology trainees, without much in the way of practical teaching modules, examination logs, or live board certification proficiency. Earlier this year, Helm et al proposed standardizing the TBSE sequence to minimize omitted areas of the body, which may become an imperative tool for streamlined resident teaching and optimal screening encounters. (7) Depending on patient body surface area, mobility, willingness to disrobe, and adornments, multiple factors may restrict full view of a patient’s skin, however. For instance, some patients refuse a gown or removal of certain clothing items (e.g., undergarments, socks, wigs), and based on a recent cross-sectional study by McClatchey et al, if the patient has never had a TBSE, they are less willing to have sensitive areas of the body examined by a provider of the opposite gender. They also, nonetheless, reported that 84% of patients expected genital and breast examination during TBSE but most did not feel as though they required a chaperone in the room. (8) Taking this tug-of-war into account to arrive at the most thorough TBSE, perhaps TBSE expectations should be explored at the outset, such as pre-visit literature and staff explanation of TBSE logistics. Wholly, we should not shame, coerce, or assume patient compliance with ‘total’ examination but instead view as much as patients are able and comfortable to show us, welcoming that we have the opportunity to take care of them and screen for cancer in any capacity. In underserved or limited-budget practice regions, lesion-directed versus TBSE may be the only possible screening method and may even attract more patients to a screening facility. (9)

Frequency of TBSE also remains under debate. In the U.S., dermatologist density is 3.4 per 100,000 people (10), a ratio that cannot undertake mass screening of all Americans in a particular age range like mammography and dental screenings do. In an ideal universe, the aforementioned high-risk groups would receive expedited screening, but the Goldilocks scenario applies; no one eats the porridge at the perfect temperature all the time. No practice or patient population is comparable with respect to its risk factors, geography, medical care access, education, or expectations.

Managing this balance includes many tactics and schedule permutations specific to each dermatologist’s milieu. Most practices give patients with a history of melanoma priority status so that any visit cancellations or delays are rescheduled preferentially. However, some of these at-risk patients defer yearly TBSE upon checkout and schedule an appointment only when a lesion of concern arises. In the opposite corner are those patients who deem the recommended TBSE interval as too infrequent, which poses a delicate dilemma and another cohort of risks, namely that the patient may become (or continue to be) overly fixated on the small details of every skin lesion, and develop the habit of expecting frequent and self-directed biopsies. This may lead to a difficult discussion about oversampling lesions and the potential for many scars, copious re-excisions for ambiguous lesional pathology, and a trend away from prudent clinical care. In addition, multiple visits incur more patient co-pays and absence from school, work, or home. Most dermatologists therefore advise all patients to call for a more acute visit if there is a lesion of concern and also recommend taking home photographs. Further, self- or partner-examination between visits is an intuitively valuable screening adjunct. In 2018, the USPSTF recommended behavioral skin cancer prevention counseling and self-examination only for younger-age cohorts with fair skin (6 months to 24 years), but again its utility in specialty practice was not qualified. This amassed more confusion, so the AAD Association subsequently issued a statement to support safe sun-protective practices and diligent self-screening for changing lesions for all patients, as earlier detection and management of skin cancer can lead to decreased morbidity and mortality from these neoplasms. (5)

My expedition into the literature was a quandary. We are considered to be part of a patient’s cancer surveillance team, but no single body can decide whom should be screened, how often, and if it matters for survival. Moreover, throwing a wider net for screening leaves no availability for dermatologists to care for other skin conditions or allow acute visit slots for worrisome evolving lesions. What do we do? Despite being a small specialty, we have a large duty in this cancer arena, because the incidence of melanoma in 2018 was almost 100,000 cases (American Cancer Society); our training is strong, our community mindedness is large, and our organizing bodies promote stewardship of resources and expertise to patients most in need. Leaning on the consensus statements by the AAD and AADA above, you can shape your community’s approach to its skin cancer risk factors and screening practices and save lives, and the data will follow.

Conclusion: Perform TBSEs in a consistent manner with a consistent message, while attempting to dictate the number of appointment slots and preferences allotted for high risk patients. Stay tuned. As of September 2019, the ABD says there are just under 15,000 board-certified dermatologists in the U.S.; our brain trust and resolve will help us define optimal skin cancer screening practices. We need to be “loud voices” in the governing bodies that shape guidelines that are "just right."

Point to remember: TBSE is the bedrock of dermatologic cancer screening, but its methods and frequency are yet to be standardized into agreed-upon guidelines. Amassed data from the USPSTF, AAD, and well-respected academic centers are attempting to determine which high-risk groups should be preferentially screened, namely those with history of skin cancer, immunosuppression, indoor tanning and/or many blistering sunburns, and several other genetic parameters.

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Our Expert’s Viewpoint

Jeffrey J. Miller, MD
Professor and Chair of Dermatology
PennState Health and College of Medicine

Dr. Rosamilia thoroughly reveals the Naked Truth About Total Skin Examination, the dermatologist’s most important physical exam tool. Expanding on her Goldilocks metaphor, we, as a highly specialized group, have a challenge and an opportunity to get the TBSE “just right.” The challenge is to develop and validate a standardized process to perform the TBSE. The opportunity is to introduce the TBSE into medical school curricula and residency program training. To date, our dermatology specialization, which has enabled each of us to develop our own efficient and effective TBSE, creates a coordination problem in that we do not have a common language or procedure for the TBSE that could lead to integration of the TBSE into medical school curriculum focused on the physical exam skills. The other opportunity is to provide the evidence on the value of the TBSE that would then lead to more widespread incorporation of TBSEs into routine physical exams by primary care clinicians and to endorsement by the United States Preventative Services Task Force (USPSTF). I agree with Dr. Rosamilia that we would need to define the population who will benefit from the TBSE, especially given the mismatch between our current workforce and patient demand. I believe that machine-based learning, artificial intelligence, and automated total body skin scanning will augment our ability to access more patients in the future but will never replace the TBSE by an experienced, compassionate dermatologist.

I vividly remember the time I had to tell my patient that I missed his biopsy-proven melanoma on his left flank at his 12-month follow up visit. I was humbled by my own limitations and used this failure as an opportunity to rededicate myself to the TBSE. Having a standardized process to perform my TBSE helps me create a mental checklist to examine all body parts.

I believe that we must continue to advance the TBSE as a physician exam skill that is “just right” through further investigation, including studies which examine the patient’s perspective of the TBSE.

1. Risica PM, Matthews NH, Dionne L, Mello J, et al. Psychosocial consequences of skin cancer screening. Prev Med Rep. 2018;10:310-316.

2. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, et al. Screening for skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:429-435.

3. US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Barry MJ, et al. Behavioral counseling to prevent skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;319:1134-1142.

4. AAD statement on USPSTF recommendation on skin cancer screening. Schaumburg, IL: American Academy of Dermatology; July 26, 2016. https://www.aad.org/media/news-releases/aad-statement-on-uspstf.

5. AADA responds to USPSTF recommendation on skin cancer prevention counseling. Rosemont, IL: American Academy of Dermatology Association; March 20, 2018. https://www.aad.org/media/news-releases/skin-cancer-prevention-counseling.

6. Johnson MM, Leachman SA, Aspinwall LG, Cranmer LD, et al. Skin cancer screening: recommendations for data-driven screening guidelines and a review of the US Preventive Services Task Force controversy. Melanoma Manag. 2017;4:13-37.

7. Helm MF, Hallock KK, Bisbee E, and JJ Miller. Optimizing the total body skin exam: an observational cohort study [published online February 15, 2019]. J Am Acad Dermatol 2019; Feb 15 [Epub ahead of print]

8. McClatchey CT, Reddy P, Weiss E, Kohn J, et al. Patient comfort and expectations for total body skin examinations: A cross-sectional study. J Am Acad Dermatol. 2019;81(2):615-617.

9. Hoorens I, Vossaert K, Pil L, Boone B, et al. Total-body examination vs lesion-directed skin cancer screening. JAMA Dermatol. 2016;152:27-34.

10. Glazer AM and DS Rigel, MD. Analysis of trends in geographic distribution of US dermatology workforce density. JAMA Dermatol. 2017;153(5):472-473.

11. American Cancer Society:https://www.cancer.org/cancer/melanoma-skin-cancer/about/key-statistics.html

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