Incidental lesions found in veterans referred to dermatology: The value of a dermatologic examination

Published:January 23, 2015DOI:


      Few studies have evaluated the detection of incidental skin cancers.


      We sought to evaluate the rate of incidental cutaneous malignancies in routine dermatology consults.


      This was a retrospective chart review of all dermatology consults at the Minneapolis Department of Veterans Affairs Medical Center over 8.25 years. Inclusion criteria included an in-person clinic visit within 18 months of the initial consult date. Patients with an in-person skin examination by a dermatologist in the 18 months before consult date were excluded.


      Of 28,405 consults sent during the study period, 17,174 met inclusion criteria. In all, 2257 (13.1%) patients had 1 or more biopsied incidental lesions. Half (50.3%; n = 1674) of the 3328 biopsied incidental lesions were malignant, which included 1187 patients. The per-person detection rate for an incidental malignant lesion was 6.9% (1187/17,174). There were 87 incidental melanomas identified in 84 patients. The per-person detection rate for an incidental melanoma was 0.5% (84/17,174). The most frequent anatomical location for biopsied incidental malignancies was the head and neck (53.9%). Incidental melanomas were most frequently located on the back (33.3%).


      Nondiverse patient population and conservative detection rate estimates are limitations.


      An in-person skin examination by a trained dermatologist is important for detection of skin malignancies. This may have implications for teledermatology.

      Key words

      Abbreviations used:

      BIL (biopsied incidental lesion), IPDE (in-person dermatologic examination), PC (primary care), PCP (primary care provider), VA (Department of Veterans Affairs)
      To read this article in full you will need to make a payment
      AAD Member Login
      AAD Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • American Cancer Society
        Cancer facts and figures.
        American Cancer Society, Atlanta (GA)2014: 1-70
        • Wolff T.
        • Tai E.
        • Miller T.
        Screening for skin cancer: an update of the evidence for the US Preventive Services Task Force.
        Ann Intern Med. 2009; 150: 194-198
        • Gerbert B.
        • Maurer T.
        • Berger T.
        • et al.
        Primary care physicians as gatekeepers in managed care: primary care physicians' and dermatologists' skills at secondary prevention of skin cancer.
        Arch Dermatol. 1996; 132: 1030-1038
        • Lowell B.A.
        • Froelich C.W.
        • Federman D.G.
        • Kirsner R.S.
        Dermatology in primary care: prevalence and patient disposition.
        J Am Acad Dermatol. 2001; 45: 250-255
        • Chen S.C.
        • Pennie M.L.
        • Kolm P.
        • et al.
        Diagnosing and managing cutaneous pigmented lesions: primary care physicians versus dermatologists.
        J Gen Intern Med. 2006; 21: 678-682
        • Viola K.V.
        • Tolpinrud W.L.
        • Gross C.P.
        • Kirsner R.S.
        • Imaeda S.
        • Federman D.G.
        Outcomes of referral to dermatology for suspicious lesions: implications for teledermatology.
        Arch Dermatol. 2011; 147: 556-560
        • Aldridge R.B.
        • Naysmith L.
        • Ooi E.T.
        • Murray C.S.
        • Rees J.L.
        The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas.
        Acta Derm Venereol. 2013; 93: 689-692
        • Geller A.C.
        • O'Riordan D.L.
        • Oliveria S.A.
        • Valvo S.
        • Teich M.
        • Halpern A.C.
        Overcoming obstacles to skin cancer examinations and prevention counseling for high-risk patients: results of a national survey of primary care physicians.
        J Am Board Fam Pract. 2004; 17: 416-423
        • Federman D.G.
        • Reid M.
        • Feldman S.R.
        • Greenhoe J.
        • Kirsner R.S.
        The primary care provider and the care of skin disease: the patient's perspective.
        Arch Dermatol. 2001; 137: 25-29
        • Kirsner R.S.
        • Federman D.G.
        Lack of correlation between internists' ability in dermatology and their patterns of treating patients with skin disease.
        Arch Dermatol. 1996; 132: 1043-1046
        • Wagner Jr., R.F.
        • Wagner D.
        • Tomich J.M.
        • Wagner K.D.
        • Grande D.J.
        Diagnoses of skin disease: dermatologists vs nondermatologists.
        J Dermatol Surg Oncol. 1985; 11: 476-479
        • Feldman S.R.
        • Fleischer Jr., A.B.
        • Chen J.G.
        The gatekeeper model is inefficient for the delivery of dermatologic services.
        J Am Acad Dermatol. 1999; 40: 426-432
      1. Cancer Research UK (2013). Cancer statistics report: Skin cancer. London: Cancer Research UK.

        • Warshaw E.M.
        • Hillman Y.J.
        • Greer N.L.
        • et al.
        Teledermatology for diagnosis and management of skin conditions: a systematic review.
        J Am Acad Dermatol. 2011; 64: 759-772
        • Tan E.
        • Yung A.
        • Jameson M.
        • Oakley A.
        • Rademaker M.
        Successful triage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT trial).
        Br J Dermatol. 2010; 162: 803-811
        • Lim A.C.
        • Egerton I.B.
        • See A.
        • Shumack S.P.
        Accuracy and reliability of store-and-forward teledermatology: preliminary results from the St George teledermatology project.
        Australas J Dermatol. 2001; 42: 247-251
        • Whited J.D.
        Teledermatology research review.
        Int J Dermatol. 2006; 45: 220-229
        • Warshaw E.M.
        • Lederle F.A.
        • Grill J.P.
        • et al.
        Accuracy of teledermatology for nonpigmented neoplasms.
        J Am Acad Dermatol. 2009; 60: 579-588
        • Warshaw E.M.
        • Lederle F.A.
        • Grill J.P.
        • et al.
        Accuracy of teledermatology for pigmented neoplasms.
        J Am Acad Dermatol. 2009; 61: 753-765
        • Diepgen T.L.
        • Mahler V.
        The epidemiology of skin cancer.
        Br J Dermatol. 2002; 146: 1-6