Use of Photographs Illustrating ABCDE Criteria in Skin Self-examination

Dermatologists support public education campaigns using photographic references of nevi and melanoma, and they distribute brochures with these images to their patients in the belief that such images teach people to self-detect changing nevi and melanomas.¹ Photographic images of melanomas optimize people's spontaneous image recognition.² After the initial review, it is unclear how reference materials are used. We explored the use of educational material by people at risk to develop melanoma.

Methods

The study population, composed of 174 participants with melanoma and their cohabitating partners, was randomized into either the dyadic (couple) or single learning condition of an educational intervention to learn skin self-examination (SSE). Specifics on the inclusion and exclusion criteria and the intervention have been published.^3-5 Briefly, at the initial visit, subjects participated in a demonstration of the ABCDE rule (asymmetry, border irregularity, color variegation, diameter ≥6 mm, and evolution), and a 15-minute SSE skills training session with quiz questions. They were given an enabling kit consisting of the ABCDE card, a lighted hand magnifying glass, and a millimeter ruler.

At the 4-month follow-up visit, the research assistant (S.O.) asked a series of questions regarding use of the ABCDE card. Frequency of checking the card (daily, 2-3 times per week, once per week, once per month, 1-2 times since received card, never) and the storage location of the card were ascertained. The institutional review boards of Dartmouth-Hitchcock Medical Center and Northwestern University approved the research protocol. Statistical findings were determined by χ² analysis.

Results

There was no difference in the demographic characteristics of age, sex, education, income, and marital status between the dyadic (n=92) and the single (n=82) learning conditions. Use of the illustrated card was associated with dyadic learning (P=.03) (Table). Of the 86 participants who never used the card, 84% indicated that they did not need it as they “got it” during the training session (n=72). The cards were stored in the following locations: bedroom (n=56), bathroom (n=27), kitchen drawer (n=21), and living room (n=2). Sixty-eight participants did not know where the card was located. Cards stored in bedrooms and bathrooms were referred to more than those stored in other locations (P=.02). For those in the single learning condition, the most common reason for referring to the card was to show the partner what to check (n=25). For those in the dyadic learning condition, the card was used to check the color variation.

Table.

Checking the ABCDE Card

Learning Condition (N = 174)	Frequency of Referring to ABCDE Card
	1 Time/wk	1-2 Times/mo	1-2 Times Total	Never
Dyadic (n=92)	2	20	36	34
Single (n=82)	1	8	21	52

Abbreviation: ABCDE, asymmetry, border irregularity, color variegation, diameter 6 mm or larger, and evolution.

Comment

Recognizing a melanoma requires associating the image with the model of a melanoma stored in the visual memory. Models are constructed from our visual experience.⁶ People cannot recognize things that they have not seen before; however, having seen a melanoma once during supervised learning, people create a visual model.

People in our study used the reference material once to help the partner create a model of a melanoma in his or her memory. Some referred to the ABCDE card images to help check color variation and added this information to their global visual model. Since people did not use the reference material to check border irregularity or diameter, it may be inferred that these parameters are more easily understood and incorporated into the learner's visual memory. Many did not need to use reference materials.

The intervention used active learning by performing exercises with a millimeter ruler to demonstrate measuring the diameter and a lighted magnifying lens to identify the border and colors of a mole. The findings from this research using active learning of skills cannot be generalized to patients who are asked to learn passively by reading a magazine or a brochure given to them by a physician.

As dermatologists consider resource allocation for patient education, it behooves us to adopt ways that may be more beneficial to the patient. Having a patient use a ruler to measure a mole and a magnifying lens with nurse supervision may be more efficient in eliciting behavioral change than distributing color brochures to patients. Furthermore, having the patients practice using their own nevi may increase the relevance of the ABCDE materials. Finally, the images of melanomas used in learning materials are often of advanced cases to illustrate all of the features, but these more extreme images may be frightening or confusing to patients. Patients appear to internalize the concept of checking for change in a mole by viewing examples of nevi with 1 or 2 features.