[Academic Presentation] History, Current Status, and Development Strategies — Dermoscopy in China

Article reprinted from: Chinese Medical Abstracts – Dermatology, Issue 2, 2017.

Authors: Cui Yong, Lin Yan, Yu Ruixing, Wang Lei, Ran Yuping, Liu Jie, Sun Qiuning, Li Hang, Meng Rusong, Zou Xianbiao, Zheng Yajie, Xu Feng, Zhang Xingqi, Xie Fengying

Skin imaging technology is one of the fastest‑advancing fields in dermatologic diagnosis. By enabling in vivo, noninvasive, real‑time, and dynamic observation of skin lesions, it assists clinicians in diagnosing diseases and assessing their severity. Dermoscopy, a transillumination microscope for the skin surface, utilizes oil immersion, illumination, and optical magnification to visualize subepidermal structures, the dermo‑epidermal junction, and the papillary dermis—features that are invisible to the naked eye. Often referred to as the “stethoscope of dermatology,” it is the most widely used and well‑established technique within skin imaging.

Dermoscopy was initially used primarily to evaluate melanoma and other pigmented skin disorders; today, its applications have expanded considerably. It is increasingly recognized and embraced by clinicians for noninvasive assessment, diagnostic support, and differential diagnosis in vascular conditions, erythematous‑scaly diseases, nail and hair disorders, as well as benign and malignant skin tumors. Moreover, dermoscopy offers distinct and valuable advantages in clinical decision‑making, such as dynamically monitoring lesions over time and guiding the extent of surgical excision in dermatopathology. However, dermoscopy cannot replace histopathological examination, and clinicians must possess a high level of expertise in interpreting dermoscopic images, which requires dedicated training to master.

This article provides a review from three perspectives: the brief history of dermoscopy, the current state of its development in China, and strategies for its future advancement.

1 A Brief History of Dermoscopy

As early as 1663, scholars were already using microscopes to examine nailfold vessels. In 1893, Paul Unna first introduced the term “diaskopie” (transillumination) in German, employing an oil-immersion microscope to observe skin surfaces. In the early 20th century, the German dermatologist Johann Saphier was the first to incorporate an integrated light source into the dermoscope, replacing external illumination and thereby enhancing lighting quality; he also coined the German term “dermatoskopie” for the first time. By the 1950s, the American dermatologist Leon Goldman had pioneered the English term “dermoscopy” and began using dermoscopes to examine and evaluate cutaneous pigmented lesions, including nevi and melanomas—applications that remain among the primary uses of dermoscopy today. Following the 1970s, the use of dermoscopy became increasingly widespread. In 1971, Rona Mac Kie reported on the clinical significance of dermoscopy for the preoperative diagnosis of pigmented skin disorders and its role in differentiating benign from malignant pigmented lesions.

In the 1980s, Fritsch, Pechlaner, Pehamberger, and Soyer, among others, published numerous studies that advanced the use of dermoscopy in routine dermatological diagnosis. In 1989, the first consensus conference on dermoscopy was held in Hamburg, Germany, where standardized terminology for dermoscopic imaging was established and subsequently published the following year. From the 1990s onward, image‑based dermoscopic analysis methods gradually emerged and gained widespread adoption.

In 2001, the first polarized-light dermoscope was introduced. Although it differs slightly from oil-immersion dermoscopes in image acquisition, its non-contact design avoids compressing blood vessels, thereby producing clearer vascular images. In February of the same year, the first World Dermoscopy Congress was held in Rome, further refining the structural features of dermoscopes and establishing a two-step classification system and diagnostic criteria for pigmented skin lesions. As of the time this article was written, a search on MED-LINE using the keyword “dermoscopy” revealed that dermoscopy-related research papers have increased annually since the 1990s, with a total of 3,367 publications to date (http://www.ncbi.nlm.nih.gov/pubmed).

2 Current Status of Dermoscopy in China

The promotion and application of dermoscopy in China began relatively late; the earliest published paper indexed on CNKI dates back to 1999. On MEDLINE, the number of Chinese publications in the field of dermoscopy remains limited—just over 70 entries—and their content primarily focuses on research into dermoscopic imaging techniques, the clinical utility of dermoscopy across various conditions, and case reports. By contrast, the volume of Chinese-language papers on dermoscopy is comparatively substantial and has been steadily increasing, with the total number of articles published in 2015 more than doubling that of 2013. However, most of these Chinese studies are descriptive or introductory in nature, with few addressing large-scale clinical trials or comparative analyses of different dermoscopic imaging modalities. This suggests that systematic research in this area still requires further strengthening in China.

Although dermoscopy has only been in use in China for a relatively short time, we have already witnessed encouraging momentum: (1) At the academic‑organizational level, the Dermatology and Venereology Branch of the Chinese Medical Association established the Subspecialty Group for Digital Diagnosis of Skin Diseases as early as 2011 (with plans to soon set up a Dermoscopic Imaging Group); the Dermatology and Venereology Professional Committee of the Chinese Association for Integrated Traditional Chinese and Western Medicine founded a Dermoscopic Imaging Group in 2013; and in 2016, both the Dermoscopic Imaging Group under the Dermatology and Dermatocosmetic Branch of the China Association for Medical Device Industry and the Dermoscopic Imaging Group of the Dermatology Branch of the China International Exchange and Promotion Association for Healthcare established similar groups. Moreover, the Subspecialty Committee on Dermatologic Surgery of the Dermatologists’ Branch of the Chinese Medical Doctor Association, founded in 2009, also undertakes efforts to promote dermoscopy within its remit. These academic organizations have organized overseas courses, dedicated symposia, and other activities at numerous national annual meetings, thereby providing an excellent scholarly platform for advancing dermoscopy. (2) In basic research, institutions such as Beijing University of Aeronautics and Astronautics and the General Hospital of the PLA Air Force have conducted extensive work in areas like dermoscopic image recognition, yielding a series of original findings and jointly establishing “Dermoscopy China,” currently the largest online resource for dermoscopic technology. (3) With regard to monograph publishing, Chinese scholars have released five monographs or translated works on dermoscopy, including “Clinical Applications of Dermoscopy,” “Peking Union Medical College Dermoscopy Atlas,” “Dermoscopy Atlas of Pigmentary and Hair Disorders,” “Dermoscopic Image Processing Techniques,” and “Dermoscopy Atlas.” These publications present the theory and applications of dermoscopy from diverse perspectives, offering strong guidance and practical utility for enhancing Chinese dermatologists’ understanding and proficiency in this field. (4) In continuing medical education, over the past few years, major hospitals nationwide—including Peking Union Medical College Hospital, Peking University First Hospital, the General Hospital of the PLA Air Force, and the First Affiliated Hospital of Sun Yat-sen University—have successively launched several well‑known training programs on dermoscopic techniques and their clinical applications, attracting substantial participation from primary‑care dermatologists.

In addition, since 2015, the Dermatology and Venereology Branch of the Chinese Medical Association has consecutively organized two “Mirror‑Goodness, Mirror‑Beauty” National Dermoscopy Photography and Case‑Submission Contests, which have promoted the widespread adoption and clinical application of dermoscopy in China in an engaging and accessible manner, thereby playing a positive role in enhancing dermatologists’ proficiency in dermoscopic diagnosis.

3 Development Strategies for Dermoscopy in China

Dermoscopy is a well-established and mature field within dermatologic imaging, yet in China it remains relatively new. In an era where interconnectedness and widespread data sharing have become the prevailing trend, how to foster the healthy, sustainable development of dermoscopy in our country and enable it to effectively support and enhance clinical diagnosis of skin diseases is a question that warrants careful reflection—and poses a serious challenge. From a developmental perspective, concerted efforts are needed across multiple dimensions and levels of dermoscopic research and application, while also giving due consideration to proactive integration with other increasingly sophisticated technological platforms.

3.1 Establishment of a Dermoscopy Quality Management System

As a non‑invasive dermatoscopic imaging device, dermoscopy undoubtedly offers significant advantages in the auxiliary diagnosis of skin diseases, dynamic disease monitoring, and clinical decision‑making. However, several current limitations are hindering the full realization of its potential: (1) The nomenclature for dermoscopic findings remains inconsistent, with both metaphorical and descriptive terms coexisting and their interrelationships not yet fully clarified, thereby complicating user interpretation and impeding communication and knowledge sharing; (2) Systematic research and standardized correlations between dermoscopic features and results from other imaging modalities as well as histopathological findings are lacking, leading to fragmentation among different imaging‑based diagnostic tools; (3) From an equipment perspective, the market is flooded with numerous brands and models, each characterized by distinct parameters and technical specifications, which poses challenges for dermatologists in selecting appropriate devices.

In light of the foregoing, establishing a quality management system for dermoscopy is currently the most pressing task. Relevant academic organizations should conduct comparative studies of dermoscopes from different manufacturers and strive to optimize parameters tailored to the skin characteristics of the Chinese population. Nationwide dermoscopic imaging centers should develop robust mechanisms for data integration and sharing, while actively investigating the correlations—both commonalities and differences—among various dermoscopic imaging techniques. Furthermore, multi-center validation efforts should be leveraged through shared platforms; the integration of dermoscopic PACS systems at Beijing Air Force General Hospital and China-Japan Friendship Hospital serves as an exemplary initiative. Recently, the “Dermoscopy Terminology Guidelines: Consensus of the Third International Dermoscopy Society Conference” was published, and domestic experts have already undertaken its translation and interpretation, facilitating learning and understanding among dermatologists in China. A quality management system for dermoscopy is a complex, system‑wide undertaking that requires the concerted participation of relevant academic institutions, experts, and industry stakeholders.

3.  2 Bridging the Variability in Dermoscopy Expertise Among Users

According to incomplete statistics, among the more than 20,000 dermatologists nationwide, a significant proportion have already acquired portable dermoscopes through various channels, and some large hospitals’ dermatology departments have equipped themselves with dermoscopy workstations. From a hardware standpoint, China now possesses the foundational conditions necessary for the widespread implementation of dermoscopy. However, substantial variability in dermoscopic technique and interpretation skills among Chinese dermatologists currently results in tangible disparities in clinical competence.

In recent years, the publication of Chinese monographs and translated works on dermoscopy, the proliferation of dermoscopy training courses, and a variety of academic events dedicated to this field have all represented valuable efforts to bridge the gap in expertise. These initiatives have been warmly welcomed and actively embraced by dermatologists nationwide. Given that dermoscopy is a digital‑imaging–based technique characterized by non‑invasive transmission and sharing, it is essential to explore more effective training methods and dissemination channels to rapidly broaden participation and enhance educational outcomes. Leveraging online platforms to offer year‑round, on‑demand training courses, coupled with the establishment of assessment and certification systems grounded in expert consensus to evaluate both theoretical knowledge and practical skills, will help standardize training protocols and foster a more uniform level of proficiency among Chinese dermatologists in dermoscopic practice—key prerequisites for the widespread adoption of dermoscopy.

3.3 Accelerating the Development of China’s Dermoscopy Image Database

The networking of visual capabilities underpins tele‑dermatology, and all currently available skin imaging modalities—including dermoscopy—can be digitized, making them valuable components of this field. The Chinese population is predominantly of East Asian descent, and its skin characteristics, including those captured in dermoscopic images, differ from those of the established international imaging databases. From a dermoscopic perspective, it is imperative to establish a dermoscopic image database tailored to the skin features of the Chinese population. This endeavor will also leverage big data to distill and select common dermoscopic phenotypic patterns across relevant dermatologic conditions, ultimately paving the way for the development of dermoscopic diagnostic criteria specifically applicable to dermatological disorders in China. Furthermore, such a database can serve as the foundation for a remote professional education platform aimed at dermatologists and general practitioners in underserved regions, helping to bridge disparities in dermoscopic practice.

Leveraging established academic organizations and industry alliances—such as the “China Dermatology Digital Imaging Consortium,” which comprises the China-Japan Friendship Hospital, the First Affiliated Hospital of Anhui Medical University, Xijing Hospital of the Fourth Military Medical University, the First Hospital of Zhengzhou University, and the Affiliated Hospital of Guangdong Medical College—has proven to be an effective approach for aggregating and integrating dermoscopic imaging resources. The “Cloud Hospital” project in Anhui Province is one of the earliest hospital‑based telemedicine initiatives in China dedicated to dermatology; it currently encompasses more than 700 dermatologists across the province and will serve as a key source of data for China’s dermoscopic image database. As telemedicine in dermatology continues to evolve, each dermatologist will, through a collaborative “crowdsourcing” model, become both a builder and a contributor to this resource repository. By harnessing cloud technologies to manage the database and enable shared access, this effort will help elevate the overall standard of dermoscopy in China.

3.  4 Conducting research related to remote dermoscopy

The portability and reproducibility of dermoscopy enable it to outperform other dermatologic imaging modalities—such as confocal laser scanning microscopy and cutaneous ultrasound—and facilitate seamless integration with smartphones and mobile internet. Dermoscopic images have become an indispensable source of information in tele‑dermatology, significantly advancing the field. Tele‑dermoscopy, built on dermoscopic technology, has emerged as a critical component of tele‑dermatology, holding substantial value for both clinical care and medical education.

The accuracy of remote dermoscopic diagnosis and treatment is a matter of great concern to both providers and patients. Studies have shown that, overall, the diagnostic accuracy of remote dermoscopy varies considerably across different studies; however, within a given study, remote dermoscopy generally demonstrates substantial concordance or close agreement with in-person clinical findings. At present, most research in this field has been conducted abroad, while China still lacks robust studies on the diagnostic accuracy of remote dermoscopy, underscoring the urgent need for well-designed investigations to be initiated promptly. Actively integrating dermoscopy into China’s tele‑dermatology framework is also an essential step and integral component for fully realizing the clinical significance of this technology.

4 Outlook

It is reasonable to anticipate that the era of every dermatologist in China having their own dermoscope is just around the corner. Therefore, through concerted efforts across all sectors, it is imperative to promptly establish a quality‑management system for dermoscopy and a comprehensive dermoscopic image database, while also achieving uniformity in dermoscopic diagnostic standards. At the same time, we must vigorously advance both basic and applied research on dermoscopy—particularly remote dermoscopy—tailored to the Chinese population. These are pressing priorities for our field’s development. In the information age, technological advances unfold simultaneously worldwide; although China currently lacks systematic research in the dermoscopy domain, this does not preclude us from leveraging our “late‑comer advantage” to gradually narrow the gap with international counterparts and enable Chinese dermatologists to fully reap the benefits that dermoscopy offers.

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