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Dermatoscopy helps identify malignant lesions. (Avoiding Removal of Benign Lesions).

Epiluminescent microscopy, or dermatoscopy, can help dermatologists and primary care physicians--even experts--decide whether to remove a mole that falls into the "gray zone" between benign and malignant, said Dr. Mark Naylor of the University of Oklahoma, Oklahoma City.

Using a dermatoscope over time cuts down on the number of benign lesions that are removed because it provides a dearer picture of reassuring features that characterize nonmalignant lesions.

"I don't want to take off 100 seborrheic keratoses, even if I get reimbursed," he said. "It's boring and honestly not good medicine."

The $400 DermLite that Dr. Naylor carries in his pocket--he calls it a "lighted magnifying glass on steroids--is a convenient step forward from a bulky traditional dermatoscope. Yet the quality of images offered by the two types of devices is roughly comparable, according to ongoing head-to-head research that he is conducting using devices provided by DermLite, marketed by 3Gen.

DermLite's portability and the fact that it does not require oil or water on the skin make it useful for enhancing lesion analysis even in a busy clinical practice, said Dr. Naylor, who is serving as an unpaid consultant to the company that makes the device.

It may be true that DermLite will bring inexpensive dermatoscopy to mainstream dermatology, but comparing a pocket device to an epiluminescent imaging system that includes computer-aided diagnosis and digital imaging "is like comparing electrolysis to laser hair removal," said Dr. Michael Gold, a Nashville dermatologist who now incorporates both the MoleMax and the FotoFinder systems into his daily practice.

"We have the technology now I'm all for these new machines," Dr. Gold said.

Yet despite the burgeoning interest in noninvasive lesion imaging, reimbursement for getting a revved-up view of a lesion or taking a brilliant picture using one of the smart new devices continues to be elusive.

Dr. Babar K. Rao, director of the pigmented lesion clinic and dermatopathology at the Robert Wood Johnson Medical School in New Brunswick, N.J., said that noninvasive imaging falls into three basic categories--with price tags to match.

First are the new dermatoscopes, which are basically handheld magnifiers with greatly improved lighting systems and more clarity than traditional, oil-based dermoscopy units. The new devices give the physician a better view of a lesion. They are convenient, cheap, and "a feast for the eyes," in the words of Dr. Diane Thaler of Monona, Wis., who is quoted on the Web site of the popular DermLite.

These systems are only as good as the physician who uses them, since they merely enhance the view upon which a clinical judgment is made, Dr. Rao commented in an interview.

The next level of technology includes dermatoscopes that can be attached to video or digital cameras. Software can store images and rate their features according to algorithms that distinguish malignant from benign lesions.

Examples of such systems are the MoleMax and the DermoGenius Ultra. In these systems, computerized databases supplement clinical judgment by comparing lesion features with hundreds or thousands of other images categorized by experts according to the ABCD rule or other diagnostic criteria.

At the top of the line are the "machine vision" systems such as SIAscope and MelaFind, which use varying wavelengths of light like superhuman "x-ray vision." These devices calculate the quantity and exact location of structures that lie beneath the skin such as collagen, melanin, and blood.

In the case of MelaFind, which Dr. Rao is using in clinical trials, the information is sent to the computer's brain, which contains a repository of data about thousands of historic images that did or didn't prove to be melanoma.

Although the MelaFind is not yet commercially available, Dr. Gold relishes the computerized information that he obtains with the FotoFinder, which he bought for about $20,000.

"They're not cheap," he admits, but the printouts he receives from the systems can be priceless to the patient with 20 suspicious moles.

"I always tell patients this doesn't replace my eye," he said. "But I can get a better sense that you can watch this mole, and that mole should come off."

Dr. Gold has used both devices for free community melanoma screenings, and he often offers patients a choice: They can opt for an insurance-covered excision, or a $100 out-of-pocket peek at a mole that will provide noninvasive reassurance and an image that can be used as a benchmark during follow-ups over months or years.

Although insurance generally will nor cover noninvasive screening except in rare cases, Dr. Gold points out that reimbursement hurdles may change.

"Insurance companies could save a ton of money" if imaging of moles was covered at a fair rate, he said, saving patients surgery and scars from excisions that prove to be unnecessary.

Dr. Rao agrees.

"It may eventually become like an x-ray or CT scan," he said. Before operating, a physician could be reimbursed for imaging a lesion noninvasively to aid with diagnosis or surgical planning.
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Author:Bates, Betsy
Publication:Internal Medicine News
Date:Jan 15, 2003
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