Smartphone-Based Applications for Skin Monitoring and Melanoma Detection

With the advancement of mobile technologies, smartphone applications (apps) have become widely available and gained increasing attention as a novel tool to deliver dermatologic care. This article presents a review of various apps for skin monitoring and melanoma detection and a discussion of current limitations in the field of dermatology. Concerns regarding quality, transparency, and reliability have emerged because there are currently no established quality standards or regulatory oversight of mobile medical apps. Only a few apps have been evaluated clinically. Further research is needed to evaluate the utility and efficacy of smartphone apps in skin cancer screening and early melanoma detection.

Key points

•

Smartphone applications (apps) offer a unique approach to enhance the delivery of dermatologic care.
•

Despite the abundance of apps in skin cancer education and screening, few have been evaluated for clinical efficacy and none has been sufficiently accurate and reliable using established research methodologies.
•

The US Food and Drug Administration (FDA) has proposed guidelines to regulate mobile apps, but there are currently no established quality standards or regulatory oversight of mobile medical apps to ensure patient safety and minimize harm.
•

The wide availability of smartphone apps has raised important ethical concerns regarding patient confidentiality, informed consent, transparency of data ownership, and data privacy protection.
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Further studies are needed to assess the safety and efficacy of smartphone medical apps as diagnostic tools in skin cancer screening.

Introduction

According to a 2015 Pew Research Center report, 92% of US adults own a cell phone and 68% have a smartphone, up from 35% in 2011, with smartphone ownership nearing the saturation range of 83% to 86% for adults ages 18 to 49. As smartphones have rapidly gained popularity, there are now thousands of available mobile medical apps available, with a considerable number of these apps developed in dermatology, where clinical diagnosis is largely based on visual examination. Although these apps have potential to offer novel pathways to deliver health care, there are concerns regarding their safety, confidentiality, quality of content, and regulation. Hamilton, Brady and March and colleagues surveyed 229 dermatology-related apps, with those relevant to melanoma or skin cancer spanning a spectrum of functions, including reference or educational aids, self-surveillance and diagnostic tools, teledermatology, and research. More than half of the apps are free of charge, with paid apps ranging in price from $0.99 to $139.99, with a median price of $2.99. Only 33% of app descriptions explicitly stated a named dermatologist and 31% claimed involvement of doctors or a medical team whereas in 36% of apps, authorship information was not disclosed. Moreover, a case study evaluating the accuracy of 4 apps to correctly classify 60 melanoma and 128 benign control lesions found the results highly variable with three-fourths of the apps incorrectly classifying 30% or more of the melanoma lesions.

This article presents a review and characterization of various types of smartphone-based apps for skin monitoring and melanoma detection for use by the general public. The list of apps actually available at a given time changes daily so the focus is on app categories with examples, along with some of their potential advantages and pitfalls ( Table 1 ). Progress toward regulatory body–approved and scientifically evaluated mobile health apps with an update of current FDA regulation in the field of medical apps, as well as ethical challenges currently affecting the field are also discussed.

Table 1

Smartphone applications for skin cancer monitoring and detection: Pros and Cons

Smartphone Application Type	Pros	Cons
Educational—provides information on skin cancer diagnosis and/or risk factors	• Inexpensive way to educate across wide geographic area • Simple to update • Minimal potential for risk to patient	• Audience limited to those with smartphones and knowledge of technology • No process to verify quality and accuracy of information
Mole mapping—allows patients to take images of either individual moles of concern or to take own set of full-body digital images	• Inexpensive • Patient can use at home to collect own images • Easy for patient to use images during skin self-examination	• Variable image quality • Not useful for physician during screenings in office • Risk of security breech if stored on app’s server vs patient phone
Teledermatology—provides platform for patient-directed teledermatology	• Some apps are inexpensive • Access to dermatologist for patients with financial, time, geographic barriers • May be good option for routine follow-up in established dermatologist-patient relationship • Some apps integrate teledermatology visit into patients electronic medical record • Can integrate patient-performed teledermoscopy for appropriate high-risk patients	• Limited health insurance coverage • Not all treating physicians are dermatologists or licensed in a patient’s state of residence • Many apps do not adhere to standards of high-quality telemedicine • Risk of poor-quality images if taken by patient with a smartphone • Not all guarantee adequate protection of protected health information
Diagnostic—allows user to collect image of suspicious lesion and uses internal algorithm to perform a risk assessment for a lesion	• May raise awareness, encourage patients to seek medical attention • Potential for future development using validated algorithms • Inexpensive	• Currently no regulatory oversight • No quality standards • Risk of falsely reassuring patient that a skin cancer is benign and delaying diagnosis of skin cancer or causing unnecessary anxiety if wrong
Research—allows individuals to participate in research studies using their smartphone	• Can reduce research expenses by allowing informed consent, photos, clinical information to be entered via smartphone • Access to research participants nationwide • Can integrate smartphone sensors for data collection • Use of available ResearchKit by Apple facilitates design and addresses data security concerns • Can anonymize data and share with wider research community	• Limit to data that can be collected with a smartphone (no blood, tissue, genetic data) • Cannot validate patient-reported data in most cases • Limited ability to provide intervention via smartphone

Introduction

According to a 2015 Pew Research Center report, 92% of US adults own a cell phone and 68% have a smartphone, up from 35% in 2011, with smartphone ownership nearing the saturation range of 83% to 86% for adults ages 18 to 49. As smartphones have rapidly gained popularity, there are now thousands of available mobile medical apps available, with a considerable number of these apps developed in dermatology, where clinical diagnosis is largely based on visual examination. Although these apps have potential to offer novel pathways to deliver health care, there are concerns regarding their safety, confidentiality, quality of content, and regulation. Hamilton, Brady and March and colleagues surveyed 229 dermatology-related apps, with those relevant to melanoma or skin cancer spanning a spectrum of functions, including reference or educational aids, self-surveillance and diagnostic tools, teledermatology, and research. More than half of the apps are free of charge, with paid apps ranging in price from $0.99 to $139.99, with a median price of $2.99. Only 33% of app descriptions explicitly stated a named dermatologist and 31% claimed involvement of doctors or a medical team whereas in 36% of apps, authorship information was not disclosed. Moreover, a case study evaluating the accuracy of 4 apps to correctly classify 60 melanoma and 128 benign control lesions found the results highly variable with three-fourths of the apps incorrectly classifying 30% or more of the melanoma lesions.

This article presents a review and characterization of various types of smartphone-based apps for skin monitoring and melanoma detection for use by the general public. The list of apps actually available at a given time changes daily so the focus is on app categories with examples, along with some of their potential advantages and pitfalls ( Table 1 ). Progress toward regulatory body–approved and scientifically evaluated mobile health apps with an update of current FDA regulation in the field of medical apps, as well as ethical challenges currently affecting the field are also discussed.

Table 1

Smartphone applications for skin cancer monitoring and detection: Pros and Cons

Smartphone Application Type	Pros	Cons
Educational—provides information on skin cancer diagnosis and/or risk factors	• Inexpensive way to educate across wide geographic area • Simple to update • Minimal potential for risk to patient	• Audience limited to those with smartphones and knowledge of technology • No process to verify quality and accuracy of information
Mole mapping—allows patients to take images of either individual moles of concern or to take own set of full-body digital images	• Inexpensive • Patient can use at home to collect own images • Easy for patient to use images during skin self-examination	• Variable image quality • Not useful for physician during screenings in office • Risk of security breech if stored on app’s server vs patient phone
Teledermatology—provides platform for patient-directed teledermatology	• Some apps are inexpensive • Access to dermatologist for patients with financial, time, geographic barriers • May be good option for routine follow-up in established dermatologist-patient relationship • Some apps integrate teledermatology visit into patients electronic medical record • Can integrate patient-performed teledermoscopy for appropriate high-risk patients	• Limited health insurance coverage • Not all treating physicians are dermatologists or licensed in a patient’s state of residence • Many apps do not adhere to standards of high-quality telemedicine • Risk of poor-quality images if taken by patient with a smartphone • Not all guarantee adequate protection of protected health information
Diagnostic—allows user to collect image of suspicious lesion and uses internal algorithm to perform a risk assessment for a lesion	• May raise awareness, encourage patients to seek medical attention • Potential for future development using validated algorithms • Inexpensive	• Currently no regulatory oversight • No quality standards • Risk of falsely reassuring patient that a skin cancer is benign and delaying diagnosis of skin cancer or causing unnecessary anxiety if wrong
Research—allows individuals to participate in research studies using their smartphone	• Can reduce research expenses by allowing informed consent, photos, clinical information to be entered via smartphone • Access to research participants nationwide • Can integrate smartphone sensors for data collection • Use of available ResearchKit by Apple facilitates design and addresses data security concerns • Can anonymize data and share with wider research community	• Limit to data that can be collected with a smartphone (no blood, tissue, genetic data) • Cannot validate patient-reported data in most cases • Limited ability to provide intervention via smartphone

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