{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T03:26:33Z","timestamp":1785295593127,"version":"3.55.0"},"reference-count":40,"publisher":"MDPI AG","issue":"20","license":[{"start":{"date-parts":[[2025,10,21]],"date-time":"2025-10-21T00:00:00Z","timestamp":1761004800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background: Diagnosing facial melanoma, specifically lentigo maligna (LM) and lentigo maligna melanoma (LMM), is a daily clinical challenge, particularly for small or traumatized lesions. LM and LMM are part of the broader group of atypical pigmented facial lesions (aPFLs), which also includes benign look-alikes such as solar lentigo (SL), atypical nevi (AN), seborrheic keratosis (SK), and seborrheic-lichenoid keratosis (SLK), as well as pigmented actinic keratosis (PAK), a potentially premalignant keratinocytic lesion. Standard dermoscopy with handheld devices is the most widely used diagnostic tool in dermatology, but its accuracy heavily depends on the clinician\u2019s experience and the perceived difficulty of the case. As a result, many benign aPFLs are excised for histological analysis, often leading to aesthetic concerns. Reflectance confocal microscopy (RCM) can reduce the need for biopsies, but it is limited to specialized centers and requires skilled operators. Aims: This study aimed to assess the impact of personal skill, diagnostic confidence, and perceived difficulty on the diagnostic accuracy and management in the differential dermoscopic diagnosis of aPFLs. Methods: A total of 1197 aPFLs dermoscopic images were examined on a teledermoscopic web platform by 155 dermatologists and residents with 4 skill levels (&lt;1, 1\u20134, 5\u20138, &gt;8 years). They were asked to give a diagnosis, to estimate their confidence and rate the case, and choose a management strategy: \u201cfollow-up\u201d, \u201cRCM\u201d or \u201cbiopsy\u201d. Diagnostic accuracy was examined according to the personal skill level, confidence level, and rating in three settings: (I) all seven diagnoses, (II) LM vs. PAK vs. fully benign aPFLs, (III) malignant vs benign aPFLs. The same analyses were performed for management decisions. Results: The diagnostic confidence has a certain impact on the diagnostic accuracy, both in terms of multi-class diagnosis of six aPFLs in diagnostic (setting 1) and in benign vs malignant (setting 3) or benign vs. malignant\/premalignant discrimination (setting 2). The perceived difficulty influences the management of benign lesions, with easy ratings predominantly matching with \u201cfollow-up\u201d decision in benign cases, but not that of malignant lesions assigned to \u201cbiopsy\u201d. The experience level had an impact on the perception of the number of real easy cases and had no to minimal impact on the average diagnostic accuracy of aPFLs. It, however, has an impact on the management strategy and specifically in terms of error reduction, namely the lowest rates of missed malignant cases after 8 years of experience and the lowest rates of inappropriate biopsies of benign lesions after 1 year of experience. Conclusions: The noninvasive diagnosis and management of aPFLs rest on a daily challenge. Highlighting which specific subgroups of lesions need attention and second-level examination (RCM) or biopsy can help detect early malignant cases, and, in parallel, reduce the rate of unnecessary removal of benign lesions.<\/jats:p>","DOI":"10.3390\/cancers17203388","type":"journal-article","created":{"date-parts":[[2025,10,21]],"date-time":"2025-10-21T14:24:02Z","timestamp":1761056642000},"page":"3388","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Impact of Diagnostic Confidence, Perceived Difficulty, and Clinical Experience in Facial Melanoma Detection: Results from a European Multicentric Teledermoscopic Study"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1818-6275","authenticated-orcid":false,"given":"Alessandra","family":"Cartocci","sequence":"first","affiliation":[{"name":"Dermatology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7615-9187","authenticated-orcid":false,"given":"Alessio","family":"Luschi","sequence":"additional","affiliation":[{"name":"Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-5807-0664","authenticated-orcid":false,"given":"Sofia","family":"Lo Conte","sequence":"additional","affiliation":[{"name":"Unit of Diagnostic and Therapeutic Neuroradiology, Department of Neurology and Human Movement Sciences, Azienda Ospedaliero Universitaria, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4009-0659","authenticated-orcid":false,"given":"Elisa","family":"Cinotti","sequence":"additional","affiliation":[{"name":"Dermatology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesca","family":"Farnetani","sequence":"additional","affiliation":[{"name":"Department of Dermatology, University of Modena and Reggio Emilia, 41121 Modena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7193-0964","authenticated-orcid":false,"given":"Aimilios","family":"Lallas","sequence":"additional","affiliation":[{"name":"First Department of Dermatology, Aristotle University, 54124 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1326-8535","authenticated-orcid":false,"given":"John","family":"Paoli","sequence":"additional","affiliation":[{"name":"Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden"},{"name":"Department of Dermatology and Venereology, Region Vastra Gotaland, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caterina","family":"Longo","sequence":"additional","affiliation":[{"name":"Department of Dermatology, University of Modena and Reggio Emilia, 41121 Modena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5160-8997","authenticated-orcid":false,"given":"Elvira","family":"Moscarella","sequence":"additional","affiliation":[{"name":"Dermatology Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danica","family":"Tiodorovic","sequence":"additional","affiliation":[{"name":"Dermatology Clinic, Medical Faculty, University of Nis, 18000 Nis, Serbia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ignazio","family":"Stanganelli","sequence":"additional","affiliation":[{"name":"Skin Cancer Unit, Scientific Institute of Romagna for the Study of Cancer (IRCSS), 47014 Meldola, Italy"},{"name":"Department of Dermatology, University of Parma, 43121 Parma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariano","family":"Suppa","sequence":"additional","affiliation":[{"name":"Department of Dermatology, H\u00f4pital Erasme, Universit\u00e9 Libre de Bruxelles, 1050 Brussels, Belgium"},{"name":"Groupe d\u2019Imagerie Cutan\u00e9e Noninvasive, Soci\u00e9t\u00e9 Fran\u00e7aise de Dermatologie, 75009 Paris, France"},{"name":"Department of Dermatology, Institut Jules Bordet, 1070 Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3186-2861","authenticated-orcid":false,"given":"Emi","family":"Dika","sequence":"additional","affiliation":[{"name":"Oncologic Dermatology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy"},{"name":"Oncologic Dermatology, Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7878-4955","authenticated-orcid":false,"given":"Iris","family":"Zalaudek","sequence":"additional","affiliation":[{"name":"Department of Dermatology and Venereology, University of Trieste, 34141 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4201-8490","authenticated-orcid":false,"given":"Maria Antonietta","family":"Pizzichetta","sequence":"additional","affiliation":[{"name":"Department of Dermatology and Venereology, University of Trieste, 34141 Trieste, Italy"},{"name":"Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCSS, 33081 Aviano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4479-9961","authenticated-orcid":false,"given":"Jean Luc","family":"Perrot","sequence":"additional","affiliation":[{"name":"Dermatology Unit, University Hospital of St-Etienne, 42270 Saint Etienne, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Imma","family":"Savarese","sequence":"additional","affiliation":[{"name":"Soc Dermatologia Pistoia-Prato, USL Toscana Centro, 51100 Pistoia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8268-0529","authenticated-orcid":false,"given":"Magdalena","family":"\u017bychowska","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Faculty of Medicine, University of Rzeszow, 35-310 Rzeszow, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Rubegni","sequence":"additional","affiliation":[{"name":"Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3869-8593","authenticated-orcid":false,"given":"Mario","family":"Fruschelli","sequence":"additional","affiliation":[{"name":"Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7291-4990","authenticated-orcid":false,"given":"Ernesto","family":"Iadanza","sequence":"additional","affiliation":[{"name":"Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7212-573X","authenticated-orcid":false,"given":"Gabriele","family":"Cevenini","sequence":"additional","affiliation":[{"name":"Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6691-4310","authenticated-orcid":false,"given":"Linda","family":"Tognetti","sequence":"additional","affiliation":[{"name":"Dermatology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,21]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Conforti, C., and Zalaudek, I. 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