Profile of the use of dermoscopy among dermatologists in Brazil (2018),

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Anais

Brasileiros

de

Dermatologia

www.anaisdedermatologia.org.br

INVESTIGATION

Proﬁle

of

the

use

of

dermoscopy

among

dermatologists

in

Brazil

(2018)

夽,夽

Carlos

Baptista

Barcaui

a_,_∗

_,

_Helio

_Amante

_Miot

b

a_Department_of_Dermatology,_Hospital_{Universitário}_Pedro_Ernesto,_Universidade_do_Estado_do_Rio_de_Janeiro,_Rio_de_Janeiro, RJ,Brazil

b_Department_of_Dermatology_and_{Radiotherapy,}_Faculdade_de_Medicina,_Universidade_Estadual_Paulista,_Botucatu,_SP,_Brazil

Received15November2019;accepted15April2020 Availableonline15July2020

KEYWORDS Brazil; Datacollection; Dermatology; Dermoscopy Abstract

Background: Dermoscopyincreasesthediagnosticaccuracyindermatology.Theaspectsrelated totraining,usageproﬁle,orperceptionsofusefulnessofdermoscopyamongdermatologistsin Brazilhavenotbeendescribed.

Objectives: Toevaluatetheproﬁleoftheuseofdermoscopyandtheperceptionoftheimpact ofthetechniqueonclinicalpractice.

Methods: TheBrazilianSocietyofDermatologyinvitedallmemberstocompleteanonlineform with20itemsregardingdemographicdata,dermatologicalassistance,useofdermoscopy,and perceptionsoftheimpactofthetechniqueonclinicalpractice.Theproportionsbetweenthe categorieswerecomparedbyanalysisofresidualsincontingencytables,andp-values<0.01 wereconsideredsigniﬁcant.

Results: Theanswersfrom815associates(9.1%ofthoseinvitedtoparticipate)wereassessed, 84%ofwhomwerefemale,and71%ofwhomwereyoungerthan50yearsofage.Theuseof dermoscopywasreportedinthedailypracticeof98%ofdermatologists:88%reportedusing itmore thanonce aday. Polarized lightdermoscopywas the mostused method(83%) and patternanalysiswasthemostusedalgorithm(63%).Thediagnosisandfollow-upofmelanocytic lesionswasidentifiedasthemainuseofthetechnique,whilethebenefitforthediagnosisof inflammatorylesionswasacknowledgedbylessthanhalfofthesample(42%).

Studylimitations: Thiswasanon-randomizedstudy.

Conclusion: DermoscopyisincorporatedintotheclinicalpracticeofalmostallBrazilian derma-tologists,anditisrecognizedforincreasingdiagnosticcertaintyindifferentcontexts,especially forpigmentedlesions.

夽 _How_to_cite_this_article:_Barcaui_CB,_Miot_HA._Proﬁle_of_the_use_of_dermoscopy_among_{dermatologists}_in_Brazil_(2018)._An_Bras_Dermatol.

2020;95:602---8.

夽 _Study_conducted_at_the_Brazilian_Society_of_Dermatology,_Rio_de_Janeiro,_RJ,_Brazil. ∗_{Corresponding}_author.

E-mails:cbbarcaui@gmail.com,cbarcaui@uerj.br(C.B.Barcaui).

https://doi.org/10.1016/j.abd.2020.04.007

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Introduction

Dermoscopy is a non-invasive auxiliary method that

increases the accuracy of the diagnosis of melanoma, as

long as the dermatologist is adequately trained in the

technique.1---3_Its_use_has_been_proven_to_reduce_the_number

ofunnecessarybiopsiesinbenignlesions.1,4,5_For_these

rea-sons,dermoscopyisconsideredthestandardmethodinthe

managementofskincancerandmonitoringhigh-riskgroups,

andisincludedincurrentguidelinesforclinicalpracticein

severalcountries.6---8_In_addition_to_its_primary_application_in

neoplasms,thenumberofindicationsforthistechniquein

inﬂammatorydiseases,infectiousdiseases,onychopathies,

andalopeciaisincreasing.

Theaspectsrelatedtotraining,usageproﬁle,or

percep-tionsoftheimpactofdermoscopyamongdermatologistsin

Brazilhavenotbeendescribed.Thisstudyaimedtoreveal

thefrequencyandmannerinwhichmembersoftheBrazilian

SocietyofDermatology(SociedadeBrasileirade

Dermatolo-gia[SBD])useand perceivethebeneﬁtsofdermoscopyin

theirdailypractice,andtodescribethelimitingfactorsfor

theuseofthistechniqueinBrazil.

Methods

SBDinvitedallmemberstovoluntarilyansweranelectronic

survey(onlineform)containing20questions(Table1),

con-structing a non-randomized sample (by adherence). The

questionswerepreparedbasedonthestudycarriedoutin

EuropebytheInternationalDermoscopySociety,inaddition

todemographicanddermatologicalassistancedata.9,10

The questionnairewasavailableonlinefromJune27to

July 11,2018.If theparticipantansweredNOtoquestion

nine,thequestionnairewasinterruptedinquestion10.

The answers were tabulated in MsExcel 2013, and

assessed forduplications, anomalousvalues, andpatterns

ofabsence.11

The data ofcomplete questionnairesweresummarized

asapercentageofresponses(qualitativevariables).

Conﬁ-dence intervals (95% CI) were calculated from 10,000

resamples(bootstrap).12_Quantitative_variables_were

repre-sentedasmeanandstandarddeviation(SD)ormedianand

quartiles(p25−p75),ifnormalitywasnotassessedbythe

Kolmogorov-Smirnovtest.13

The chi-squaredtestandthechi-squaredtest fortrend

were used to compare the proportions between the

sub-groups. Multinomial analyses were tested based on the

analysisof residues in the contingency table. Ap-value <

0.01wasconsideredsigniﬁcant.

Results

The questionnairewassent toall8,884SBDmembers and

wasanswered infull by 9.1%(n=815) volunteers.Table 2

presentsthemaindemographicdataofprofessionalactivity.

The followingwerenoteworthy:predominance of women,

age less than 50 years,less than 20 yearsof professional

activity,andgreaterrepresentativenessofthestatesofthe

SoutheastandSouth.

The main results related tothe trainingand proﬁle of

useof dermoscopy areshown in Table 3.The use of

der-moscopy in dermatological practice was reported by the

vastmajorityofrespondents(97.7%),withahighdaily

fre-quency.Thereasonsmentionedbythosewhodonotuseit

werelack ofconﬁdence inthetechnique (26%,n=5),not

beingwellreimbursedbyhealthplans(26%,n=5),

unavail-abilityofequipmentintheofﬁce(26%,n=5),lackoftraining

(21%,n=4),considering ituseless(16%,n=3),considering

theequipmentexpensive(16%,n=3),takingtoolong(5%,

n=1), not beingnecessary toestablish the diagnosis (5%,

n=1),consideringthatthemagnifyingglassissufﬁcient(5%,

n=1), and due to receiving patients already referred for

excision(5%,n=1).

Thefrequencyoftrainingindermoscopyduringmedical

residencywashigherfortherespondentswithshorterlength

ofexperienceinthespecialty(p<0.01).

Theformalmeansofcontinuingeducationindermoscopy

(books,classroomcourses,andconferences)werethemost

usedamongthosesurveyed.Themostwidelyusedalgorithm

fordiagnosingpigmentedlesionswaspatternanalysis.

Theperception oftheusefulnessofdermoscopyamong

thesampled dermatologistsis shown inTable 4. Brazilian

dermatologistsvaluetheusefulnessofdermoscopyforthe

diagnosisofmelanoma,monitoringofmelanocyticlesions,

anddiagnosisofpigmentedtumors;theyunderestimateits

usefulnessin the diagnosis ofinﬂammatory lesionsand in

thefollow-upofnon-melanocyticlesions(p<0.01).

Table5presentsthepercentageofuseofdermoscopyin

tumorsand inﬂammatorylesions.The frequencyof useof

dermoscopyin pigmented and non-pigmentedtumors was

higherthanthatofinﬂammatorydermatoses(p<0.01).

Regarding the degree of conﬁdence in the use of the

technique for the diagnosis of inﬂammatory diseases and

pigmentedandnon-pigmentedtumors(Table6),therewas

alowerdegree ofconﬁdencein theuseof dermoscopyin

inﬂammatorylesions(p<0.01).

Table 7 presents the perception of associates

regard-ingtheadvantages ofdermoscopy inseveralapplications.

Whencomparedwitheachother,anincreasewasobserved

inconﬁdenceintheclinicaldiagnosis,earlydiagnosisof

ini-tialmelanoma,andlesionfollow-up;inturn,onlyapartial

perceptionof thedocumentationfor legal purposes,

stor-ageofimages,andreductionofthepatients’anxiety was

observed.Theincreaseinremunerationwasnotperceived

bydermatologistsasanadvantageofusingdermoscopy.

Inaddition,724(88%)ofrespondentsbelievedthat

der-moscopypromotedanincreaseinthenumberofdiagnosed

melanomascomparedto naked-eye examination,and 660

(81%)reportedthatitreducedtheexcisionofbenignlesions.

Discussion

This was a stimulated, non-randomized surveyconducted

bysendingelectroniccommunicationstoallSBDmembers.

Despitethemethod,therewasanadequaterepresentation

of the associates regarding sex, age group, and

distribu-tionamongthegeographicalregionsregionsofthecountry.

Accordingtoa2017survey,78%ofthemembersarefemale,

themedianageis43years,andtheSoutheasternand

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Table1 QuestionnairesubmittedtomembersoftheBrazilianSocietyofDermatology(2018).

Questions Answers:

1.Whatisyourgender? Female Male 2.Howoldareyou?

3.Inwhichenvironmentdoyoupractice dermatology?

Privateofﬁce

Privatehospitalorclinic Universityhospital Publicoutpatientclinic 4.Howlonghaveyoubeenpracticing

dermatologyasaspecialist? 5.Whatisthenumberofpatientsyou

seepermonth?

6.Whatisthemeannumberofskin cancerpatients(alltypes)youseeper month?

7.Didyoureceivedermoscopytraining aspartofyourresidencyorgraduate degreeindermatology?

a)Yes b)No 8.Inadditiontoyourtrainingduring

residencyorgraduateschool,whattype oftrainingindermoscopydidyou undergo?

a)Dermoscopycourse b)Onlinedermoscopycourse c)Conferences/Congresses d)Books/Atlases

e)Mentor/Tutor f)Notraining 9.Doyouusedermoscopyinyourdaily

practice?

a)Yes b)No 10.Ifyoudonotusedermoscopy,please

indicatethereasonswhynot:

a)Idonotconsideritusefulformypractice b)Theequipmentisveryexpensive

c)Thedermatoscopeisnotavailableinmyofﬁce d)Idonothavetrainingindermoscopy

e)Iamnotconﬁdentenoughinmyskillsfordermatoscopicdiagnosis f)Ittakestoolong

g)Itisnotwellreimbursed h)Others

11.Howlonghaveyoubeenusing dermoscopy?

a)<2years b)2−5years c)>5years 12.Whattypeofdermatoscopedoyou

use?

a)Non-polarizedimmersioncontact(contactwithskin,interfaceliquid,e.g.,

oil,alcohol)

b)Polarizedlightdermatoscope c)Dermatoscopewithdigitalcamera

d)Digitalvideodermoscopy(e.g.,Fotoﬁnder,Molemax,etc.) 13.Inyourdailypractice,howoftendo

youusedermoscopy?

a)Lessthanonce/month b)1−4times/month c)Morethanonce/week d)Atleastonce/day 14.Inyouropinion,howusefulis

dermoscopyforthefollowing?

a)Diagnosisofmelanoma:Useful/Notveryuseful/Notuseful

b)Monitoringofmelanocyticlesions:Useful/Notveryuseful/Notuseful c)Diagnosisofpigmentedtumors:Useful/Notveryuseful/Notuseful d)Diagnosisofnon-pigmentedtumors:Useful/Notveryuseful/Notuseful e)Diagnosisofinﬂammatorylesions:Useful/Notveryuseful/Notuseful f.Follow-upofnon-melanocyticskinlesions:Useful/Notveryuseful/Not useful

g)Follow-upofnon-melanocyticskinlesions:Useful/Notveryuseful/Not useful

15.Whenexaminingpatientswiththe followingskinproblems,inwhat percentageofcasesdoyouuse dermoscopy:

a)Pigmentedtumors:<10%/11%_−30%/31%_−50%/51%_−70%/>70%ofcases b.Non-pigmentedtumors:<10%/11%−30%/31%−50%/51%−70%/>70%of cases

c

¸.Inﬂammatorylesions:<10%/11%−30%/31%−50%/51%−70%/>70%of cases

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Table1(Continued)

Questions Answers:

16.Whichalgorithmdoyouregularlyuse forthedermatoscopicdiagnosisof pigmentedlesions? a)ABCDrule b)CASH c)Menziesalgorithm d)Seven-pointrule e)Patternanalysis

f)Idonotsystematicallyuseanyparticularalgorithm 17.Howconﬁdentareyouinyour

dermoscopyskillsforassessingthe followingtypesoflesions?

a)Pigmentedtumors:Confident/Notveryconfident/Notconfident b)Non-pigmentedtumors:Confident/Notveryconfident/Notconfident c)Inflammatorylesions:Confident/Notveryconfident/Notconfident 18.Inyouropinion,themainadvantages

ofusingdermoscopyinclude:Strongly agree/Partially

agree/Disagree/Indifferent

a)Diagnosisofearly-stagemelanoma b)Allowslesionfollow-up

c)Reducesthenumberofbiopsiesorunnecessaryexcisions d)Increasesconﬁdenceintheclinicaldiagnosis

e)Improvesthewayimagesarestored f)Reducespatientanxiety

g)Improvesdocumentationforlegalpurposes h)Increasesremuneration

19.Doyouthinkthattheuseof

dermoscopyhasincreasedthenumberof melanomasdetectedbyyouwhen comparedwithnaked-eyeexamination?

a)Yes b)No

20.Inyourpractice,howdidtheuseof dermoscopyinﬂuencethenumberof excisionsofbenignlesionsthatyou performed?

a)Decreaseinthenumberofexcisionsofbenignlesions b)Increaseinthenumberofexcisionsofbenignlesions c)Nochangeinthenumberofexcisionsofbenignlesions

Table2 Demographicanddermatologicalcaredataforthe sample(n=815). Variable Results Sex---n(%) Female 681(84) Male 134(16) Agegroup---n(%) ≤35years 261(32) 36−50years 321(39) >50years 233(29)

Timeindermatologicalpractice---n(%)

≤10years 392(48) 11−20years 184(23) 21−30years 139(17) >30years 100(12) Geographicalregion---n(%) SE 501(62) S 136(17) NE 98(12) MW 47(6) N 23(3)

Consultationspermonth---mean(SD) 224(141) Oncologicalconsultationspermonth

---median(p25−p75)

15(8−30) Typeofpractice---n(%)

Privatepractice 720(88) Privatehospital 274(34) Publicoutpatientclinic 243(30) Universityhospital 169(21)

Regardingtheenvironmentinwhichthemembers

prac-ticedermatology,itisclear thatmanyhadmorethanone

type of activity, with the vast majority (88%) working in

privatepractices.Over 55%of thesample hadbeen

prac-ticingdermatologyforlessthan15years,reﬂectingayoung

society;27%oftheparticipantshadbeenpracticingthe

spe-cialtyforlessthanﬁveyears.

The total numberof patients attended per month was

quiteheterogeneousamongtheinterviewees,withamean

of 224 cases. It is noteworthy that half of the sample

reportedattending less than 15 cancer cases per month.

Fromthesedata, skin cancer representsonly 6.6% of the

totaldermatosesseenmonthlybythedermatologist,which

reﬂects the interest in areas of dermatology other than

oncology. The customization of dermatological practice,

suchascosmiatry,pediatricdermatology,orleprosy

exper-tise,canrepresentthedifferentimpactsofdermoscopyon

theindividualrealityofeachprofessional.

Only60% ofthe participantshadsome typeoftraining

in dermoscopy during their dermatology residency. From

a historical perspective, dermoscopy is a relatively new

method;despitebeingusedsince1663fortheobservation

ofnailcapillaries,itonlygainedpopularityinthelate1980s

withthe description of pattern analysisand the

develop-mentof the portablemanual dermatoscope.15---17 _The _ﬁrst

consensusontheterminologyusedintheEnglishlanguage

was published in 1990; only recently there was a study

publishedevaluatingthereproducibility of theseterms in

thePortugueselanguage.18,19_Nonetheless,_the_frequency_of

trainingindermoscopyduringresidencywashigheramong

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Table3 Datarelatedtothetrainingandproﬁleofdermoscopyuse(n=815).

Variable Results 95%CIa

Makesusedermoscopy---n(%) 796(98) 97−99

Frequencyofuse---n(%)

≥Onceperday 723(88) 87−90

≥Onceperweek 60(7) 6−9

≥Oncepermonth 20(3) 2₋3

<Oncepermonth 12(2) 1−2

Dermoscopydevice--- n(%)

Polarizedlight 677(83) 81−85

Contact 320(39) 36−42

Dermatoscopecoupledtodigitalcamera 162(20) 17−22

Videodermoscopy 87(11) 9−13

Dermoscopytrainingduringmedicalresidency---n(%) 489(60) 57₋63 Traininginresidencyinrelationtotimeinprofessionalactivity---n(%)

≤10years 355(91) 88₋93

11−20years 90(49) 42−55

21₋30years 29(21) 14₋26

>30years 15(15) 8−21

Typeofupdatingindermoscopy---n(%)

Book/Atlas 712(87) 85−89 Congress/Conference 669(82) 79−84 Classroomcourses 662(81) 78₋83 Onlinecourses 113(14) 12−16 Mentor/Tutor 95(12) 10₋14 None 9(1) 1−2

Diagnosticalgorithminpigmentedlesions---n(%)

Patternanalysis 515(63) 60−66

Noparticularalgorithm 143(18) 15−20

ABCD 125(15) 13−17

Menzies 18(2) 1−3

Seven-point 14(2) 1₋3

a_95%_conﬁdence_interval_based_on_10,000_resamples_(bootstrap).

Table4 PerceptionofBraziliandermatologistsregardingtheusefulnessofdermoscopy(n=815).

Variable---n(%) Useful Notveryuseful Notuseful

Diagnosisofmelanoma 809(99)a ₅₍₁₎b ₁_(-)b

Follow-upofmelanocyticlesions 804(99)a ₁₀₍₁₎b ₁_(-)b

Diagnosisofpigmentedskintumors 801(99)a ₁₂₍₁₎b ₂_(-)b

Diagnosisofnon-pigmentedskintumors 711(87) 96(12)b ₈₍₁₎b

Follow-upofnon-melanocyticlesions 532(65)b ₂₄₄₍₃₀₎a ₃₉₍₅₎a

Diagnosisofinﬂammatorylesions 345(42)b ₄₀₇₍₅₀₎a ₆₃₍₈₎a

Analysisofresidualsincontingencytable:a_p_<_0.01_above_expected;b_p_<_0.01_below_expected.

Expectedvalues:useful(90%),notveryuseful(9%),notuseful(1%).

Table5 Percentageofuseofdermoscopyinspeciﬁcsituations(n=815).

Variable---n(%) >70% 31%−70% 11%−30% <10% Pigmentedtumors 583(72)a ₁₉₂₍₂₄₎b ₂₀₍₃₎b ₂₀₍₃₎b

Non-pigmentedtumors 464(57)a ₂₅₂₍₃₁₎b ₅₂₍₆₎b ₄₇₍₆₎b

Inﬂammatorylesions 138(17)b ₃₂₁₍₃₉₎a ₁₆₉₍₂₁₎a ₁₈₇₍₂₃₎a

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Table6 Degreeofconﬁdenceintheuseofdermoscopyforthediagnosisofpigmentedtumors,non-pigmentedtumors,and inﬂammatorydiseases(n=815).

Variable--- n(%) Confident Somewhatconfident Notconfident

Pigmentedtumors 630(77)a ₁₇₂₍₂₁₎b ₁₃₍₂₎b

Non-pigmentedtumors 516(63)a ₂₆₁₍₃₂₎b ₃₈₍₅₎b

Inﬂammatorylesions 209(26)b ₄₄₅₍₅₅₎a ₁₆₁₍₂₀₎a

Expectedvalues:confident(55%),somewhatconfident(36%),notconfident(9%).

Table7 Perceptionoftheadvantagesofusingdermoscopyaccordingtothestatementsbelow(n=815).

Variable---n(%) Itotallyagree Ipartiallyagree I’mindifferent Idonotagree Diagnosisearly-stagemelanoma 730(90)a ₈₁₍₁₀₎b ₁₍₋₎b ₃₍₋₎b

Allowslesionfollow-up 758(93)a ₅₃₍₇₎b ₁₍₋₎b ₃₍₋₎b

Reducesbiopsiesorunnecessaryexcisions 641(79)a ₁₅₈₍₁₉₎ ₂₍₋₎b ₁₄₍₂₎b

Increasesconﬁdenceinclinicaldiagnosis 747(92)a ₆₆₍₈₎b ₁₍₋₎b ₁₍₋₎b

Improveshowimagesarestored 573(70) 173(21)a ₅₀₍₆₎ ₁₉₍₂₎b

Reducespatientanxiety 498(61)b ₂₄₈₍₃₀₎a ₃₈₍₅₎ ₃₁₍₄₎b

Improvesdocumentationforlegalpurposes 543(67) 191(23)a ₅₃₍₇₎ ₂₈₍₃₎b

Increasesremuneration 72(9)b ₂₁₅₍₂₆₎a ₂₀₀₍₂₅₎a ₃₂₈₍₄₀₎a

Expectedvalues:Itotallyagree(68%),Ipartiallyagree(19%),I’mindifferent(6%),Idon’tagree(7%).

gradualincorporationofthetechniqueintothetrainingof

newspecialists.

Themainreasonsmentionedbythosewhodonotuse

der-moscopywerelackofconﬁdenceintheirskillsandlackof

training.Thevastmajoritysoughtadditionaltrainingat

con-gresses,conferences,courses,andbooks.Asitisastandard

methodforthemanagementofskincancerandisincluded

inthecurrentguidelinesofclinicalpracticeinseveral

coun-tries,itisessentialtoimprovetheformalteachingofthis

techniqueintheservicesaccreditedbytheSBD.However,

refresher coursesofferedat symposiaandcongressesplay

animportantroleinupdating,especiallyforthosewhohave

beenpracticingdermatologyforlonger.

Among the reasons given by those who do not use

dermoscopy, the fact that it is not well reimbursed by

healthcareplans(26%)andthehighpriceofequipment(16%)

areworthmentioning.Whilethoseareirrelevantarguments

from the scientiﬁc standpoint, they reﬂect the Brazilian

realityandmaysuggestagreaterrolefortheSBDasaclass

entityinchampioningitsdiagnosticproceduresinstateand

privateregulatoryagencies.

The maintypeofdermatoscopeusedwasthepolarized

light one(83%), whichwasexpectedgiven theportability

and the hybrid use (polarized and non-polarized light) of

currentdevices.

Regarding theusefulness of dermoscopyfor the

Brazil-ian dermatologist,the preference andthegreater degree

of conﬁdence in the use in tumors, especially pigmented

lesions, and the much less frequent use in inﬂammatory

conditionswerenoteworthy.Infact,dermoscopywas

pop-ularizedbecauseit increasedaccuracy inthe diagnosisof

melanoma;however,theincreasinguseofthetechniquein

trichology,onychology, andthediagnosisofinfectious and

inﬂammatory lesions should be promoted toimprove the

population’sdermatologicalassistance.

Over 80% of respondents use pattern analysis or do

notusealgorithms in theirdaily practice,which probably

reﬂectsthedegreeofexpertiseandaselectionbiasinthe

sample studied. Simpliﬁed algorithms were developed so

that non-experts could also diagnose melanoma, even at

theexpenseoflow speciﬁcity.Forthedermatologist,

pat-tern analysis is the method that best reﬂects the way in

whichtheimagesareinterpreted;moreover, itisthebest

methodtoteachdermoscopyforthediagnosisofmelanoma

byresidents.20,21

Thelimitationsofthestudyaremainlythelack of

ran-domizationresultingfromthespontaneousadherenceofthe

inviteddermatologists,whichcanimpairthegeneralization

ofthedata;however,thisdidnotpreventconsistentresults

frombeingunveiled.

Studiesofpatientcareproﬁlesandtheuseof

technolo-gies shouldbe repeatedperiodicallyin orderto subsidize

dermatologicalmedicaleducationactionsandtounderstand

theassistancedemandsoftheassociatesofdermatological

societies.

Conclusions

Dermoscopyhasbeenincorporatedintotheclinicalpractice

ofalmostallBraziliandermatologists,especiallythosewho

arelessthan50yearsoldandhavepracticedtheprofession

forlessthan20years.Only60%ofBraziliandermatologists

received formaltraining in dermoscopy during their

resi-dency.ThemostwidelyuseddermatoscopeinBrazilisthe

polarizedlightdevice,whilethemostwidelyused

diagnos-ticalgorithmis pattern analysis.In the perceptionof the

Braziliandermatologist,dermoscopyismorebeneﬁcialfor

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Financial

support

Nonedeclared.

Authors’

contributions

CarlosBaptistaBarcaui:Approvaloftheﬁnalversionofthe

manuscript;conceptionandplanningofthestudy;

elabora-tionandwritingofthemanuscript;obtaining,analyzing,and

interpretingthedata;effectiveparticipationinresearch

ori-entation;intellectualparticipationinpropaedeuticand/or

therapeuticconductofstudiedcases;criticalreviewofthe

literature;criticalreviewofthemanuscript.

HelioAmante Miot:Statistical analysis;approvalofthe

ﬁnalversionofthemanuscript;elaborationandwritingof

themanuscript;obtaining, analyzing,andinterpretingthe

data;effectiveparticipationinresearchorientation;critical

reviewoftheliterature;criticalreviewofthemanuscript.

Conﬂicts

of

interest

Nonedeclared.

Acknowledgements

TheauthorswouldliketothankJulioCosta,of theSBD IT

Department.

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