On March 11, 2020, the World Health Organization declared the outbreak of coronavirus disease 2019 (COVID-19) a pandemic, leading to an abrupt widespread shift to teledermatology, with postponement of nonessential in-office medical and surgical services, according to American Academy of Dermatology (AAD) recommendations.1 Perspectives have been offered regarding skin cancer management during the pandemic2; however, the current literature is lacking guidance on skin cancer screening and prevention during the COVID-19 era.
Preliminary data show a 34.3% reduction in skin cancer referrals from February to April 2020 compared to the same period in 2019. The authors also presented a subsequent reduction in the number of skin cancer diagnoses in March 2020 compared to March 2019.3 Although the COVID-19 public health emergency should be prioritized by all health care workers, the duty to maintain disease prevention remains.
We aim to provide recommendations for this urgent topic. Our goal is finding balance in preventing an increase in the incidence of and mortality from skin cancer that results from delayed detection, while conserving personalprotective equipment and minimizing exposure, by patients and clinical personnel, to the severe acute respiratory syndrome coronavirus 2. A primary benefit of skin cancer screening lies in the ability to detect melanoma, which is associated with higher mortality than the more common nonmelanoma skin cancers, basal and cutaneous squamous cell carcinomas. We place preeminence on screening directed toward detecting melanoma. The main screening method that dermatologists employ is the total-body skin examination (TBSE). Another widely encouraged and utilized component in skin cancer prevention is patient education, emphasizing avoidance of risk factors, undertaking protective factors, and providing clear instructions for performing the patient-led skin self-examination (SSE).
Teledermatology Essentials for Skin Cancer Screening
Arguably, dermatology possesses the most potential for successfully utilizing telemedicine. Teledermatology has become widely implemented across the United States, secondary to the implications of the current pandemic. A report by Perkins and colleagues4 provided a positive outlook in the preliminary transition to teledermatology beginning in March 2020, though reported time of use was relatively short (3 weeks). A May 2020 article in Dermatology News provided tips for implementing telemedicine for practices.5
We agree with the comprehensive screening algorithm for teledermatology presented by Perkins and colleagues4 (Figure 1A in their report) and recommend the following for the screening and prevention of skin cancer:
• Patients with any characteristics of increased risk, including a personal or family history of melanoma, large congenital nevi, many melanotic nevi, dysplastic nevi, and Fitzpatrick skin types I and II,6 should be prioritized for an in-person visit for TBSE.
• Immunosuppressed patients, particularly organ transplant recipients and those with a history of skin cancer, should be prioritized for an in-person visit for TBSE.
• Established patients evaluated and determined to be at average risk for skin cancer should be offered a teledermatology visit. Suspicious findings during these visits should be prioritized for an in-person visit, with subsequent biopsy and follow-up.
• New patients should be offered a teledermatology visit.
These recommendations must be reviewed alongside each patient’s risk for travel and being present in person as well as other factors that might place the patient at increased risk for COVID-19.
Total-body skin examination, a widely used tool in the dermatologist’s tool kit, presents minimal risk to patients while providing important data for each dermatology patient’s profile, ultimately directing patient care. The role of TBSE in skin cancer screening and prevention has been in discussion even prior to the current pandemic. The US Preventive Services Task Force (USPSTF) has not declared a role for TBSE in recent years; however, USPSTF recommendations are formulated using data from all forms of screening, not only dermatologist-led interventions. Accordingly, USPSTF recommendations target primary care. The AAD has released statements addressing the role of TBSE and skin cancer prevention in the past, when necessary, to provide clarity.7