W e have all had patients for whom melanoma surveillance is a particular challenge. These patients may have a history of multiple melanomas, a strong family history, a highly anxious personality, or a trunk full of dysplastic nevi. Standard methods of following these patients may include very frequent follow-up, photographs of lesions that do not meet our biopsy threshold but do not altogether reassure us, measurement and verbal descriptions of lesions to observe, or lowering of the biopsy/excision threshold so that any minimally suspicious lesions are removed. These subjective methodologies do not have evidence-based support but are currently the most common and the most intuitive mechanisms at our disposal. Less-Than-Optimal Approaches Though widely accepted, these approaches are less than optimal. Hand-written notes, no matter how meticulous and descriptive, do not capture subtle changes in a mole from one visit to the next. Also, there is no way for notes to help identify newly emerging atypical moles, remembering that half of all melanomas do not arise out of pre-existing nevi. Although photos are a step above chart notations, they can be misleading if not inaccurate. The quality of the images varies widely based on the type of photography (film versus digital), lighting, the resolution of the images and the skill of the photographer. It is difficult, if not impossible, to use poor-quality photos as a basis of comparison — and sometimes that determination isn’t made until the patient has left the office. Additionally, the distance at which the photo was taken fixes forever the degree of detail that can be discriminated. What’s more, physicians typically photograph an individual mole, which again overlooks the very real possibility of a melanoma emerging de novo and being missed on follow-up. Photographs taken in the office are often the result of a spontaneous decision made in the course of a patient’s visit. Thus, every 6 months, these patients tie up an exam room for an extended period of time and the end result is a chart full of photos of different moles, taken over a period of years, possibly taken by different people, under different lighting conditions. While the intent — documentation of the patient’s skin — was correct, the process is flawed in its execution. The do-it-yourself method is not the organized, methodical, professional approach we need to provide the highest quality care. More Sophisticated Methods of Documentation Some more sophisticated options for documenting moles exist, such as dermoscopy, also known as epiluminescence microscopy (ELM) or surface micros-copy. This non-invasive technique enables in vivo microscopic examination of skin lesions. It is intended to help distinguish between benign and malignant pigmented skin lesions. The technique involves applying immersion oil or polarized light to skin, which eliminates light reflection from the skin surface and renders the stratum corneum transparent. Then a magnifying lens allows examination of the structures of the epidermis and epidermal-dermal junction. These images can then be stored with a mounted film or digital camera. Dermoscopy can be effective in tracking individual moles. But it does not meet the need for a total body imaging system. With dermoscopy, a physician would have to simultaneously photograph every mole on a patient’s body and document that no other moles were present on skin that was not photographed. There is an alternative for documenting the skin of high-risk melanoma patients — total body photography. If done correctly, total body photography can provide a highly accurate, objective record of a patient’s skin and serve as valuable baseline for comparison that dermatologists heretofore have not had. The Challenge of High-Risk Patients Managing the high-risk melanoma patient can be challenging. Identifying the high-risk melanoma patient isn’t the hard part. Family history and personal history of melanoma are red flags. Some physicians look at the patient’s lifestyle such as frequent sunburns during childhood. But the most obvious indicator is visual. High-risk patients have more than a hundred moles on their bodies — we all have patients with many more. Other high-risk patients have clinically or histologically proven dysplastic nevi. Applying the ABCDs of melanoma (Asymmetry, Border irregularity, Color variegation and Diameter) to some of these patients would target 20 nevi for removal — which is neither practical nor in the patient’s best interest. At a glance, we know these types of patients have dysplastic nevi, and we want to identify the emerging melanoma amidst the background of stable, but distracting, nevi that will never develop into malignancies. Our challenge lies in tracking these patients and weeding through the “noise” to find lesions that are changing or are new, and doing this as early in the developing melanoma as possible. So what exactly are we looking for? In my practice, I use two simple steps to identify concerning lesions. First, I ask the patient if there are any moles they think have changed or are new. Second, during a skin exam I look for a mole or moles that don’t match the patient’s mole pattern. For example, a patient may have a dysplastic nevi pattern of dark, asymmetrical moles. Then a mole appears that is more intense in coloration, with more pronounced asymmetry. Ugly ducklings like this demand closer examination, and if the concern is strong enough, excision. A patient’s anxiety can make tracking difficult. We’ve told patients to be vigilant and so, with such scrutiny, it may seem that every spot on their bodies is changing. Unless I have objective data about the particular lesions in their medical record, it is their memory against mine. If I agree, the lesion is removed. However, if I think the lesion is not worrisome, I must embark upon that familiar discussion in which we try to applaud patients for their interest in self-examination and yet discount their latest findings. Neither of these options addresses the real and often unspoken worry that the patient is actually correct and that they’ll be carrying that melanoma around until their next follow-up appointment. Perhaps more than we want to admit, we remove those lesions to assuage our own fears. Defensive medicine is real in dermatology, too. A final challenge in tracing high-risk melanoma patients is simply recognizing that most atypical nevi will never evolve into melanoma; just one in thousands will make that deadly transformation. It is also recognizing that melanoma is just as likely to develop in skin that appears healthy. The relatively low risk of developing melanoma and the high-risk consequences if the patient does develop melanoma, creates a precarious position for us. Not only must we be diligent in our tracking of these high-risk patients, we also must be open to new technologies and processes that will enhance our ability to identify early-stage melanomas. The Case for Total Body Photography I became aware of total body photography early in residency, and it immediately appealed to me. Having a comprehensive photographic map of the patient’s entire skin surface for basis of comparison made logical sense. Total body photography simply serves as the medical record we would generate with words and measurements if we had enough time and a good way to write it. When the patient’s visible skin surface is documented during a single photographic session by a biomedical photographer with high-resolution digital photography, we eliminate many of the problems we typically face in following high-risk patients. The work product is an established, non-varying set of views with standardized lighting and a non-competing background. The digital images, stored on a CD-ROM, can be accessed and referred to just as we would a patient’s earlier notes. This photographic session is scheduled separately, eliminating the photoshoot delays of the do-it-yourself approach. Using the record in a busy practice is simple. When a patient returns for follow-up, our nurses have pre-loaded the patient’s CD into a laptop computer. I perform a skin examination, paying particular attention to lesions the patient identifies as changing or ones that I think are suspicious. Then, we use the CD to check those particular lesions. Occasionally, a “field check” is useful, especially for trunks. However, there is no need to check each frame of our total body photo library if clinical examination fails to spark any concern. But it is exceptionally useful to have that picture of the left forearm or other portion of the body if a potentially new lesion appears cause for concern. Patients also receive a copy of their total body photography CD, which they can use for self-exams at home. I encourage my high-risk melanoma patients to check their skin once each month, and they can view their skin frame by frame to identify (and mark if necessary) new or changing lesions. Research done at the Memorial Sloan-Kettering Cancer Center in New York City shows that patients who used digital photographs in conjunction with their self-exams correctly identified new or changed moles 72.4% of the time, compared to 60.2% for people who checked their skin without photos. In addition to improving detection rates, most high-risk patients seem to feel empowered by having a copy of their photographic record. They seem to approach the self-exam process with a sense of confidence. What Advantages Do Commercially Taken Images Offer? Some of you may question why a commercial total body photography program is better than the photos you might take in your practice. Speaking from my own experience, there are several clinical and practice management advantages. From a clinical perspective, using a professional total body photography system provides standardized organization for photos. The poses are always the same, they always appear in the same order, are always shot on the same background, with the same lighting and by a professional photographer. And because the data are compressed high-resolution images, I can zoom into each of the images for a closer, more detailed view without losing important resolution. With HIPAA concerns, I like that the patient’s images reside on a CD, rather than on my laptop. That way, I don’t have to worry about unauthorized access to sensitive medical information. The CD is placed in the patient’s file with other medical records between appointments. It is worth noting that total body photography has been assigned CPT codes by the American Medical Association and is recognized by a growing number of insurers as a reimbursable expense. A Final Word Total body photography is not the “silver bullet” for those of us caring for high-risk melanoma patients. It is merely a tool that provides an accurate, standardized baseline of a patient’s skin and helps provide quality patient care. We must continue to do the things we were trained to do and do them extremely well. Visual exams remain the most important screen for melanoma. Photographs should be used as a secondary screen and then only as a baseline for comparison to determine if change has occurred, whether in an existing nevus or emergence of a new lesion. With melanoma on the rise, we owe it to our patients and to ourselves to do everything to improve the chances of early diagnosis and survival. Total body photography provides a valuable baseline for comparing changes in the skin.
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Overcoming Challenges in Melanoma Surveillance
W e have all had patients for whom melanoma surveillance is a particular challenge. These patients may have a history of multiple melanomas, a strong family history, a highly anxious personality, or a trunk full of dysplastic nevi. Standard methods of following these patients may include very frequent follow-up, photographs of lesions that do not meet our biopsy threshold but do not altogether reassure us, measurement and verbal descriptions of lesions to observe, or lowering of the biopsy/excision threshold so that any minimally suspicious lesions are removed. These subjective methodologies do not have evidence-based support but are currently the most common and the most intuitive mechanisms at our disposal. Less-Than-Optimal Approaches Though widely accepted, these approaches are less than optimal. Hand-written notes, no matter how meticulous and descriptive, do not capture subtle changes in a mole from one visit to the next. Also, there is no way for notes to help identify newly emerging atypical moles, remembering that half of all melanomas do not arise out of pre-existing nevi. Although photos are a step above chart notations, they can be misleading if not inaccurate. The quality of the images varies widely based on the type of photography (film versus digital), lighting, the resolution of the images and the skill of the photographer. It is difficult, if not impossible, to use poor-quality photos as a basis of comparison — and sometimes that determination isn’t made until the patient has left the office. Additionally, the distance at which the photo was taken fixes forever the degree of detail that can be discriminated. What’s more, physicians typically photograph an individual mole, which again overlooks the very real possibility of a melanoma emerging de novo and being missed on follow-up. Photographs taken in the office are often the result of a spontaneous decision made in the course of a patient’s visit. Thus, every 6 months, these patients tie up an exam room for an extended period of time and the end result is a chart full of photos of different moles, taken over a period of years, possibly taken by different people, under different lighting conditions. While the intent — documentation of the patient’s skin — was correct, the process is flawed in its execution. The do-it-yourself method is not the organized, methodical, professional approach we need to provide the highest quality care. More Sophisticated Methods of Documentation Some more sophisticated options for documenting moles exist, such as dermoscopy, also known as epiluminescence microscopy (ELM) or surface micros-copy. This non-invasive technique enables in vivo microscopic examination of skin lesions. It is intended to help distinguish between benign and malignant pigmented skin lesions. The technique involves applying immersion oil or polarized light to skin, which eliminates light reflection from the skin surface and renders the stratum corneum transparent. Then a magnifying lens allows examination of the structures of the epidermis and epidermal-dermal junction. These images can then be stored with a mounted film or digital camera. Dermoscopy can be effective in tracking individual moles. But it does not meet the need for a total body imaging system. With dermoscopy, a physician would have to simultaneously photograph every mole on a patient’s body and document that no other moles were present on skin that was not photographed. There is an alternative for documenting the skin of high-risk melanoma patients — total body photography. If done correctly, total body photography can provide a highly accurate, objective record of a patient’s skin and serve as valuable baseline for comparison that dermatologists heretofore have not had. The Challenge of High-Risk Patients Managing the high-risk melanoma patient can be challenging. Identifying the high-risk melanoma patient isn’t the hard part. Family history and personal history of melanoma are red flags. Some physicians look at the patient’s lifestyle such as frequent sunburns during childhood. But the most obvious indicator is visual. High-risk patients have more than a hundred moles on their bodies — we all have patients with many more. Other high-risk patients have clinically or histologically proven dysplastic nevi. Applying the ABCDs of melanoma (Asymmetry, Border irregularity, Color variegation and Diameter) to some of these patients would target 20 nevi for removal — which is neither practical nor in the patient’s best interest. At a glance, we know these types of patients have dysplastic nevi, and we want to identify the emerging melanoma amidst the background of stable, but distracting, nevi that will never develop into malignancies. Our challenge lies in tracking these patients and weeding through the “noise” to find lesions that are changing or are new, and doing this as early in the developing melanoma as possible. So what exactly are we looking for? In my practice, I use two simple steps to identify concerning lesions. First, I ask the patient if there are any moles they think have changed or are new. Second, during a skin exam I look for a mole or moles that don’t match the patient’s mole pattern. For example, a patient may have a dysplastic nevi pattern of dark, asymmetrical moles. Then a mole appears that is more intense in coloration, with more pronounced asymmetry. Ugly ducklings like this demand closer examination, and if the concern is strong enough, excision. A patient’s anxiety can make tracking difficult. We’ve told patients to be vigilant and so, with such scrutiny, it may seem that every spot on their bodies is changing. Unless I have objective data about the particular lesions in their medical record, it is their memory against mine. If I agree, the lesion is removed. However, if I think the lesion is not worrisome, I must embark upon that familiar discussion in which we try to applaud patients for their interest in self-examination and yet discount their latest findings. Neither of these options addresses the real and often unspoken worry that the patient is actually correct and that they’ll be carrying that melanoma around until their next follow-up appointment. Perhaps more than we want to admit, we remove those lesions to assuage our own fears. Defensive medicine is real in dermatology, too. A final challenge in tracing high-risk melanoma patients is simply recognizing that most atypical nevi will never evolve into melanoma; just one in thousands will make that deadly transformation. It is also recognizing that melanoma is just as likely to develop in skin that appears healthy. The relatively low risk of developing melanoma and the high-risk consequences if the patient does develop melanoma, creates a precarious position for us. Not only must we be diligent in our tracking of these high-risk patients, we also must be open to new technologies and processes that will enhance our ability to identify early-stage melanomas. The Case for Total Body Photography I became aware of total body photography early in residency, and it immediately appealed to me. Having a comprehensive photographic map of the patient’s entire skin surface for basis of comparison made logical sense. Total body photography simply serves as the medical record we would generate with words and measurements if we had enough time and a good way to write it. When the patient’s visible skin surface is documented during a single photographic session by a biomedical photographer with high-resolution digital photography, we eliminate many of the problems we typically face in following high-risk patients. The work product is an established, non-varying set of views with standardized lighting and a non-competing background. The digital images, stored on a CD-ROM, can be accessed and referred to just as we would a patient’s earlier notes. This photographic session is scheduled separately, eliminating the photoshoot delays of the do-it-yourself approach. Using the record in a busy practice is simple. When a patient returns for follow-up, our nurses have pre-loaded the patient’s CD into a laptop computer. I perform a skin examination, paying particular attention to lesions the patient identifies as changing or ones that I think are suspicious. Then, we use the CD to check those particular lesions. Occasionally, a “field check” is useful, especially for trunks. However, there is no need to check each frame of our total body photo library if clinical examination fails to spark any concern. But it is exceptionally useful to have that picture of the left forearm or other portion of the body if a potentially new lesion appears cause for concern. Patients also receive a copy of their total body photography CD, which they can use for self-exams at home. I encourage my high-risk melanoma patients to check their skin once each month, and they can view their skin frame by frame to identify (and mark if necessary) new or changing lesions. Research done at the Memorial Sloan-Kettering Cancer Center in New York City shows that patients who used digital photographs in conjunction with their self-exams correctly identified new or changed moles 72.4% of the time, compared to 60.2% for people who checked their skin without photos. In addition to improving detection rates, most high-risk patients seem to feel empowered by having a copy of their photographic record. They seem to approach the self-exam process with a sense of confidence. What Advantages Do Commercially Taken Images Offer? Some of you may question why a commercial total body photography program is better than the photos you might take in your practice. Speaking from my own experience, there are several clinical and practice management advantages. From a clinical perspective, using a professional total body photography system provides standardized organization for photos. The poses are always the same, they always appear in the same order, are always shot on the same background, with the same lighting and by a professional photographer. And because the data are compressed high-resolution images, I can zoom into each of the images for a closer, more detailed view without losing important resolution. With HIPAA concerns, I like that the patient’s images reside on a CD, rather than on my laptop. That way, I don’t have to worry about unauthorized access to sensitive medical information. The CD is placed in the patient’s file with other medical records between appointments. It is worth noting that total body photography has been assigned CPT codes by the American Medical Association and is recognized by a growing number of insurers as a reimbursable expense. A Final Word Total body photography is not the “silver bullet” for those of us caring for high-risk melanoma patients. It is merely a tool that provides an accurate, standardized baseline of a patient’s skin and helps provide quality patient care. We must continue to do the things we were trained to do and do them extremely well. Visual exams remain the most important screen for melanoma. Photographs should be used as a secondary screen and then only as a baseline for comparison to determine if change has occurred, whether in an existing nevus or emergence of a new lesion. With melanoma on the rise, we owe it to our patients and to ourselves to do everything to improve the chances of early diagnosis and survival. Total body photography provides a valuable baseline for comparing changes in the skin.
W e have all had patients for whom melanoma surveillance is a particular challenge. These patients may have a history of multiple melanomas, a strong family history, a highly anxious personality, or a trunk full of dysplastic nevi. Standard methods of following these patients may include very frequent follow-up, photographs of lesions that do not meet our biopsy threshold but do not altogether reassure us, measurement and verbal descriptions of lesions to observe, or lowering of the biopsy/excision threshold so that any minimally suspicious lesions are removed. These subjective methodologies do not have evidence-based support but are currently the most common and the most intuitive mechanisms at our disposal. Less-Than-Optimal Approaches Though widely accepted, these approaches are less than optimal. Hand-written notes, no matter how meticulous and descriptive, do not capture subtle changes in a mole from one visit to the next. Also, there is no way for notes to help identify newly emerging atypical moles, remembering that half of all melanomas do not arise out of pre-existing nevi. Although photos are a step above chart notations, they can be misleading if not inaccurate. The quality of the images varies widely based on the type of photography (film versus digital), lighting, the resolution of the images and the skill of the photographer. It is difficult, if not impossible, to use poor-quality photos as a basis of comparison — and sometimes that determination isn’t made until the patient has left the office. Additionally, the distance at which the photo was taken fixes forever the degree of detail that can be discriminated. What’s more, physicians typically photograph an individual mole, which again overlooks the very real possibility of a melanoma emerging de novo and being missed on follow-up. Photographs taken in the office are often the result of a spontaneous decision made in the course of a patient’s visit. Thus, every 6 months, these patients tie up an exam room for an extended period of time and the end result is a chart full of photos of different moles, taken over a period of years, possibly taken by different people, under different lighting conditions. While the intent — documentation of the patient’s skin — was correct, the process is flawed in its execution. The do-it-yourself method is not the organized, methodical, professional approach we need to provide the highest quality care. More Sophisticated Methods of Documentation Some more sophisticated options for documenting moles exist, such as dermoscopy, also known as epiluminescence microscopy (ELM) or surface micros-copy. This non-invasive technique enables in vivo microscopic examination of skin lesions. It is intended to help distinguish between benign and malignant pigmented skin lesions. The technique involves applying immersion oil or polarized light to skin, which eliminates light reflection from the skin surface and renders the stratum corneum transparent. Then a magnifying lens allows examination of the structures of the epidermis and epidermal-dermal junction. These images can then be stored with a mounted film or digital camera. Dermoscopy can be effective in tracking individual moles. But it does not meet the need for a total body imaging system. With dermoscopy, a physician would have to simultaneously photograph every mole on a patient’s body and document that no other moles were present on skin that was not photographed. There is an alternative for documenting the skin of high-risk melanoma patients — total body photography. If done correctly, total body photography can provide a highly accurate, objective record of a patient’s skin and serve as valuable baseline for comparison that dermatologists heretofore have not had. The Challenge of High-Risk Patients Managing the high-risk melanoma patient can be challenging. Identifying the high-risk melanoma patient isn’t the hard part. Family history and personal history of melanoma are red flags. Some physicians look at the patient’s lifestyle such as frequent sunburns during childhood. But the most obvious indicator is visual. High-risk patients have more than a hundred moles on their bodies — we all have patients with many more. Other high-risk patients have clinically or histologically proven dysplastic nevi. Applying the ABCDs of melanoma (Asymmetry, Border irregularity, Color variegation and Diameter) to some of these patients would target 20 nevi for removal — which is neither practical nor in the patient’s best interest. At a glance, we know these types of patients have dysplastic nevi, and we want to identify the emerging melanoma amidst the background of stable, but distracting, nevi that will never develop into malignancies. Our challenge lies in tracking these patients and weeding through the “noise” to find lesions that are changing or are new, and doing this as early in the developing melanoma as possible. So what exactly are we looking for? In my practice, I use two simple steps to identify concerning lesions. First, I ask the patient if there are any moles they think have changed or are new. Second, during a skin exam I look for a mole or moles that don’t match the patient’s mole pattern. For example, a patient may have a dysplastic nevi pattern of dark, asymmetrical moles. Then a mole appears that is more intense in coloration, with more pronounced asymmetry. Ugly ducklings like this demand closer examination, and if the concern is strong enough, excision. A patient’s anxiety can make tracking difficult. We’ve told patients to be vigilant and so, with such scrutiny, it may seem that every spot on their bodies is changing. Unless I have objective data about the particular lesions in their medical record, it is their memory against mine. If I agree, the lesion is removed. However, if I think the lesion is not worrisome, I must embark upon that familiar discussion in which we try to applaud patients for their interest in self-examination and yet discount their latest findings. Neither of these options addresses the real and often unspoken worry that the patient is actually correct and that they’ll be carrying that melanoma around until their next follow-up appointment. Perhaps more than we want to admit, we remove those lesions to assuage our own fears. Defensive medicine is real in dermatology, too. A final challenge in tracing high-risk melanoma patients is simply recognizing that most atypical nevi will never evolve into melanoma; just one in thousands will make that deadly transformation. It is also recognizing that melanoma is just as likely to develop in skin that appears healthy. The relatively low risk of developing melanoma and the high-risk consequences if the patient does develop melanoma, creates a precarious position for us. Not only must we be diligent in our tracking of these high-risk patients, we also must be open to new technologies and processes that will enhance our ability to identify early-stage melanomas. The Case for Total Body Photography I became aware of total body photography early in residency, and it immediately appealed to me. Having a comprehensive photographic map of the patient’s entire skin surface for basis of comparison made logical sense. Total body photography simply serves as the medical record we would generate with words and measurements if we had enough time and a good way to write it. When the patient’s visible skin surface is documented during a single photographic session by a biomedical photographer with high-resolution digital photography, we eliminate many of the problems we typically face in following high-risk patients. The work product is an established, non-varying set of views with standardized lighting and a non-competing background. The digital images, stored on a CD-ROM, can be accessed and referred to just as we would a patient’s earlier notes. This photographic session is scheduled separately, eliminating the photoshoot delays of the do-it-yourself approach. Using the record in a busy practice is simple. When a patient returns for follow-up, our nurses have pre-loaded the patient’s CD into a laptop computer. I perform a skin examination, paying particular attention to lesions the patient identifies as changing or ones that I think are suspicious. Then, we use the CD to check those particular lesions. Occasionally, a “field check” is useful, especially for trunks. However, there is no need to check each frame of our total body photo library if clinical examination fails to spark any concern. But it is exceptionally useful to have that picture of the left forearm or other portion of the body if a potentially new lesion appears cause for concern. Patients also receive a copy of their total body photography CD, which they can use for self-exams at home. I encourage my high-risk melanoma patients to check their skin once each month, and they can view their skin frame by frame to identify (and mark if necessary) new or changing lesions. Research done at the Memorial Sloan-Kettering Cancer Center in New York City shows that patients who used digital photographs in conjunction with their self-exams correctly identified new or changed moles 72.4% of the time, compared to 60.2% for people who checked their skin without photos. In addition to improving detection rates, most high-risk patients seem to feel empowered by having a copy of their photographic record. They seem to approach the self-exam process with a sense of confidence. What Advantages Do Commercially Taken Images Offer? Some of you may question why a commercial total body photography program is better than the photos you might take in your practice. Speaking from my own experience, there are several clinical and practice management advantages. From a clinical perspective, using a professional total body photography system provides standardized organization for photos. The poses are always the same, they always appear in the same order, are always shot on the same background, with the same lighting and by a professional photographer. And because the data are compressed high-resolution images, I can zoom into each of the images for a closer, more detailed view without losing important resolution. With HIPAA concerns, I like that the patient’s images reside on a CD, rather than on my laptop. That way, I don’t have to worry about unauthorized access to sensitive medical information. The CD is placed in the patient’s file with other medical records between appointments. It is worth noting that total body photography has been assigned CPT codes by the American Medical Association and is recognized by a growing number of insurers as a reimbursable expense. A Final Word Total body photography is not the “silver bullet” for those of us caring for high-risk melanoma patients. It is merely a tool that provides an accurate, standardized baseline of a patient’s skin and helps provide quality patient care. We must continue to do the things we were trained to do and do them extremely well. Visual exams remain the most important screen for melanoma. Photographs should be used as a secondary screen and then only as a baseline for comparison to determine if change has occurred, whether in an existing nevus or emergence of a new lesion. With melanoma on the rise, we owe it to our patients and to ourselves to do everything to improve the chances of early diagnosis and survival. Total body photography provides a valuable baseline for comparing changes in the skin.
