Mount Royal University Mid Range Nursing Theory Discussion

Does Wearing a Face Mask During the
COVID-19 Pandemic Increase the Incidence
of Dermatological Conditions in Health Care
Workers? Narrative Literature Review
Robyn-Jenia Wilcha
Affiliations expand
• PMID: 34028470
1
•
PMCID: PMC8104277
DOI: 10.2196/22789
Free PMC article
Abstract
Background: COVID-19 is a health emergency. SARS-CoV-2
was discovered in Wuhan (Hubei Province, China) and has
rapidly spread worldwide, leaving no country untouched.
COVID-19 is a respiratory infection characterized by a
pneumonia of unknown etiology. It is transmitted through
respiratory droplets; for example: through breathing, talking,
and coughing. Transmission of the virus is high. Health care
workers play important roles in helping those affected by
COVID-19; this could not be done without the use of personal
protective equipment (PPE). PPE involves the use of goggles,
masks, gloves, and gowns and is known to reduce COVID-19
transmission; however, multiple reports of skin disease and
damage associated with occupational mask-wearing have
emerged.
Objective: The objective of this study is to review the literature
for newly emerging dermatological conditions as a result of
occupational mask-wearing during the COVID-19 pandemic.
Methods: A narrative review of new reports of dermatological
conditions associated with occupational mask-wearing was
carried out in May 2020 by referencing keywords including:
“covid mask dermatology,” “covid dermatological damage,”
•
“covid mask skin,” “covid N95 mask damage,” and “covid mask
skin damage” from PubMed, supplemented by searches on both
Google Scholar and ResearchGate. A total of 287 articles were
found, of which 40 were successfully included in this study, and
an additional 7 were selected from the reference lists of these 40
articles. The findings were tabulated and analyzed under the
following headings: dermatological diagnosis, causes, and
management.
Results: Qualitative analysis of the reviewed data was carried
out. A number of dermatological conditions were found to
increasingly occur owing to prolonged and frequent use of face
masks. Pressure-related injuries were often the most serious
complaint; recommendations to reduce this type of injury
include the use of hydrocolloid dressings, plastic handles,
education, and regular moisturization. Innovation in PPE as well
as services, such as virtual clinics, need to be advanced to
protect the welfare of health care staff.
Conclusions: In these unprecedented times, PPE has been an
effective barrier to the transmission of COVID-19 among health
care workers. This has allowed health care workers to provide
care to patients, with minimal risk. However, our findings
suggest that despite the obvious benefits of using face masks to
protect the respiratory system, there are also considerable health
consequences to the skin. Future research studies are required to
focus on improving face masks to ensure both the protection of
the respiratory system as well as skin care, which, according to
our study, has been overlooked.
Narrative discourse of burn injury and
recovery on peer support websites: A
qualitative analysis
Nora Cristall , Zeenib Kohja , Justin P Gawaziuk , Rae
Spiwak , Sarvesh Logsetty
Affiliations expand
• PMID: 33246671
1
3
2
1
4
DOI: 10.1016/j.burns.2020.10.004
Abstract
Although advances have been made in burn care and recovery,
less is known about the experience of living with severe burn
injury. Like other patient groups, burn survivors are now turning
to social media and shared web-based peer support resources
during recovery and continuing long after discharge. Ongoing
peer support is often part of the reclamation process after-burn
injury. Peer support and event sharing helps foster hope,
motivation and reassurance.
Objectives: To: 1) Examine and further understand the narrative
discourse of burn survivorship in peer support social media
content, 2) establish commonalities in the sharing community
and key themes related to recovery and adaptation.
Methods: This qualitative enquiry began with a comprehensive
overview of burn narratives on survivor peer generated websites.
We conducted a purposeful sampling of 21 biographies posted
on burn survivor peer and patient support websites. Participants
with greater than 30% burn injury were included that provided
narrative and discourse regarding burn recovery and
survivorship. Underlying story arcs, meaning behind sentences
and shared language of the experience were investigated using
thematic analysis.
Results: Four themes were identified: retelling of the traumatic
event; social support; body image, the new normal; and rebirth
and transformation. Accounts reflected the traumatic nature of
the event with slowed downtime, attention to details and
•
heightened recall. The value of peer and family support was a
common theme. There was attention to the challenges related to
changed body image and regaining confidence in body
appearance. Most stories also documented transitioning and
rebirth and other more positive aspects of trauma recovery.
Conclusions: Accounting the burn experience and recovery is
part of the reclamation process. Biographies document the
trauma recovery process. Storying the event is an integral
component of burn survivor community content. These online
communities have become a mainstream resource and part of the
reclamation process.
The complex experience of psoriasis related
skin pain: a qualitative study
Tone Marte Ljosaa , H Bondevik , J A Halvorsen , E Carr , A K
Wahl
Affiliations expand
• PMID: 32101532
1
2
3
4
2
DOI: 10.1515/sjpain-2019-0158
Abstract
Background and aims Psoriasis is a common chronic skin
condition, causing skin lesions with thickened and scaling skin,
as well as erythema and inflammation that may involve painful
sores, cracks, and pustules. Previously psoriasis was regarded as
a painless skin condition. However, over the past decade studies
show that skin pain is a frequently reported and bothersome
symptom in patients with psoriasis. There is however a lack of
rich narratives describing the experience of skin pain in these
patients. The aims of this qualitative study were therefore to
explore in depth how patients experience psoriasis-related skin
pain, and how they deal with it. Methods Thirteen patients with
psoriasis were recruited from a dermatology ward and outpatient
clinic. One of the investigators (TML) performed individual,
semi-structured interviews at an undisturbed room in the
hospital. Interviews were thematically analyzed using the
method of Systematic Text Condensation as described by
Malterud (2012). Results Three main themes were identified
from the interviews. First, the skin pain experience was
complex. Patients used a variety of adjectives and metaphors to
describe their pain, and their skin was sensitive to stimuli of
every-day activities. Itch was a common cosymptom, and could
both mask pain but also cause severe pain due to excessive
scratching and damage to the skin. Second, skin pain had a
negative impact on patients’ life. Skin pain reduced their
physical activity level, impaired their sleep, and made them
irritable, depressed, unconcentrated on tasks, as well as
withdrawn from other people and social activities. Third,
•
patients dealt with their skin pain in various ways. Although
some took action to relieve the pain and distract themselves
from pain, most of the patients applied maladaptive and passive
coping strategies such as put up with it, avoid painful activities,
become fearful or trivialize their pain. Conclusions The
experience of psoriasis related skin pain is complex. The pain
has a major negative impact on patients’ life in terms of
physical, emotional, cognitive, and social functions. Patients use
a variety of adaptive but most frequently maladaptive coping
strategies in order to deal with their skin pain. Implications This
study provides new and in-depth knowledge on psoriasis related
skin pain. This information is valuable for further work on pain
assessment tools and pain management recommendations
customized for skin pain experienced by patients with psoriasis.
Journal of Circuits, Systems, and Computers
Vol. 27, No. 5 (2017) 1830003 (40 pages)
#
.c World Scienti¯c Publishing Company
DOI: 10.1142/S0218126618300039
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A Systematic Review on Smartphone Skin Cancer Apps:
Coherent Taxonomy, Motivations, Open Challenges and
Recommendations, and New Research Direction¤
Qahtan M. Yas, A. A. Zaidan†, B. B. Zaidan, M. Hashim and C. K. Lim
Department of Computing, FSKIK,
Universiti Pendidikan Sultan Idris,
Tanjong Malim, Perak, Malaysia
†
[email protected]
Received 12 January 2017
Accepted 11 August 2017
Published 14 September 2017
Objective: This research aims to survey the e®orts of researchers in response to the new and
disruptive technology of skin cancer apps, map the research landscape from the literature onto
coherent taxonomy, and determine the basic characteristics of this emerging ¯eld. In addition,
this research looks at the motivation behind using Smartphone apps in the diagnosis of skin
cancer and in health care and the open challenges that impede the utility of this technology.
This study o®ers valuable recommendations to improve the acceptance and use of medical apps
in the literature. Methods: We conducted a comprehensive survey using the keywords skin
cancer,” apps,” and Smartphone” or m-Health” in di®erent variations to ¯nd all the relevant
articles in three major databases: Web of Science, Science Direct, and IEEE Xplore. These
databases broadly cover medical and technical literature. Results: We found 110 articles after a
comprehensive survey of the literature. Out of the 110 articles, 46 present actual attempts to
develop and design medical apps or share certain experiences of doing so. Twenty-eight articles
consist of analytical studies on the incidence of skin cancer, the classi¯cation of malignant
cancer or benign cancer, and the methods of prevention and diagnosis. Twenty-two articles
comprise studies that range from the evaluative or comparative study of apps to the exploration
of the desired features for skin cancer detection. Fourteen articles consist of reviews and surveys
that refer to actual apps or the literature to describe medical apps for a speci¯c specialty,
disease, or skin cancer and provide a general overview of the technology. New research direction:
With the exception of the 110 papers reviewed earlier in results section, the new directions of
this research were described. In state-of-the-art, no particular study presenting watermarking
and stenography approaches for any type of skin cancer images based on Smartphone apps is
available. Discussion: Researchers have attempted to develop and improve skin cancer apps in
several ways since 2011. However, several areas or aspects require further attention. All the
articles, regardless of their research focus, attempt to address the challenges that impede the full
utility of skin cancer apps and o®er recommendations to mitigate their drawbacks. Conclusions:
Research on skin cancer apps is active and e±cient. This study contributes to this area of
*This paper was recommended
† Corresponding author.
by Regional Editor Masakazu Sengoku.
1830003-1
Q. M. Yas et al.
research by providing a detailed review of the available options and problems to allow other
researchers and participants to further develop skin cancer apps, and the new directions of this
research were described.
Keywords: Skin cancer; apps; smartphone; m-Health; watermarking; stenography.
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1. Introduction
The interest in the topic of skin cancer has grown over the past few decades because
of the excessive damage caused by this type of disease and its widespread incidence.
Skin cancer has two basic types: malignant and benign. The proportion of people
with di®erent types of skin cancer has been increasing in recent years.13 The incidence rate for melanoma has increased signi¯cantly. Therefore, melanoma has received considerable attention from the public health ¯eld, medical prevention
campaigns, and the cancer research ¯eld. Melanoma is considered one of the deadliest
types of skin cancer and accounts for approximately 75% of deaths worldwide.13 The
main reason for skin cancer injuries that largely a®ect the epidermal layer of the skin
is due to prolonged sun exposure. Malignant melanoma (MM) is considered one of
the types of cancer that requires stupendously expensive treatment, but the cure rate
is approximately 95% only if this cancer is diagnosed and treated early.36
Several software developers have recently become interested in the development
of skin detection applications. Many technologies are currently used in the medical
¯eld; however, research in this area focusses on the use of mobile technology (i.e.,
smartphones or mobile phones) to detect skin cancer.49 Many developers show an
increasing interest in creating computer vision algorithms that work in the mobile
environment because of the mobility and portability of smartphones. Consequently,
smartphones have o®ered a good environment for the development of various newgeneration applications that use computer vision algorithms. The development of
smartphone apps for the segmentation of dermoscopic images to examine skin cancer
would be bene¯cial in the diagnosis of melanoma in terms of cost, time, and reliability.51 Smartphones are mobile devices that are smarter than the earlier generations of cellular phones, which are commonly known as feature phones. This smart
feature is due to the close resemblance of smartphones to personal computers (PCs).
Smartphones possess substantial computing power, several connectivity options,
advanced operating systems, full Internet access, and the ability to install and run
third-party apps. This ability extends the versatility and utility of smartphones,
given that they o®er users new ever-evolving functions. However, smartphones are
not only scaled-down versions of PCs but also more portable compared with laptops.
This scenario introduces the notion of context to smartphones in terms of location,
ambience, and user actions. Accordingly, the progress in smartphones has improved
health sciences and people’s awareness of the importance of having healthy lifestyle.53
The camera feature in smartphones is an innovative development that has been
incorporated into a low-cost smartphone-based intelligent system to allow people to
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Systematic Review on Smartphone Skin Cancer Apps
take images whenever and wherever. Smartphone cameras can help people in remote
areas and poor and developing countries because they can be used to scan, analyze,
and make regular skin examinations anywhere.2 An app that runs on a smartphone
with a camera could take pictures of skin abnormality. The image of the lesion could
be sent from the smartphone to a central server/computer, which would use color
and symmetry-based analysis based on arti¯cial intelligence (AI) algorithms to
classify the image as benign or malignant. Such a system has been designed to
provide a fully functional feature-rich software application with a simple graphical
user interface to analyze skin images.28 This paper aims to elucidate research e®orts,
such as those mentioned earlier that have taken place in response to the new and
disruptive technology, map the research landscape from the literature onto a
coherent taxonomy, and discover the key features that characterize this emerging
line of research, as well as the new direction of this research will propose and describe
in detail.
2. Methods
The most important keyword in the area covered by this paper is apps.” However,
in our search for apps, we exclude non-m-Health applications, such as those found on
personal digital assistants or PDAs, and non-apps, such as SMS used by conventional
mobile phones. In addition, we consider all health-care-related areas that focus on
skin cancer and research in this ¯eld but limit our scope to literature in the English
language.
2.1. Information sources
We undertook a comprehensive survey to ¯nd all the articles related to the subject of
skin cancer apps by searching on the best and most reliable databases: (1) the Science
Direct database, which o®ers access to science, technical, and medical journal articles; (2) the IEEE Xplore library of technical literature in engineering and technology; and (3) the Web of Science (WoS) service, which indexes cross-disciplinary
research in the sciences, social sciences, arts, and humanities. This selection covers
medical and technical literature and provides a broad view of the e®orts of researchers
in a wide but relevant range of disciplines.
2.2. Procedure of study selection
The procedure for the selection of the relevant studies includes searching the literature sources based on two iterations, namely, screening and ¯ltering. The ¯rst
iteration excluded duplicates and irrelevant articles by scanning the titles and
abstracts. The second iteration ¯ltered the articles after a thorough full-text reading
of the screened articles. Both iterations applied the same eligibility criteria.
1830003-3
Q. M. Yas et al.
2.3. Search
We conducted this research from the beginning of 2015 to 2016 using the search
engines Science Direct, IEEE Xplore, and WoS and entered various keywords
into their search boxes. We used a mix of keywords that contained the terms
skin cancer,” m-Health,” healthcare,” smartphone,” and apps” in di®erent
variations combined by the OR” operator. Figure 1 shows the exact query text.
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Query
“Skin cancer” OR “Skin cancer apps” OR “Mobile Health” OR “Mobile Medical
Application” OR “Medical apps” OR “Medical Smartphone apps” OR “Health
Smartphone apps” OR “Healthcare Smartphone apps”
Science Direct
36
IEEE Xplore
101
Web of Science
41
178
Screen out duplicate
170
Inclusion criteria
•
The article is in English and is a journal
or conference paper.
•
Title and abstract
scan
170
The main focus is skin cancer apps in mHealth in either one or more of the
following aspects:
133
1- Reviewing or surveying the new trend
of utilizing smartphones in medical
fields through apps,
2- Designing
or developing a medical app
or reporting the related experience and
lessons learned,
Full-text reading
133
110
3- Proposing
new
systems
or
architecture that involves smartphone
apps as a major component in skin
cancer detection, and
4- Analyzing
the use or evaluating the
performance of medical apps through a
scientific study.
Final number
of included
articles
101
Fig. 1. Flowchart of study selection, which includes the search query and inclusion criteria.
1830003-4
Systematic Review on Smartphone Skin Cancer Apps
The search excluded book chapters and other types of reports and instead focussed
on journal and conference articles given that these two avenues most likely include
up-to-date and proper scienti¯c works relevant to our survey related to the developing trend of m-Health.
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2.4. Inclusion and exclusion criteria
Articles that met the criteria in Fig. 1 were included in the review. We set an initial
target of mapping the scope of research on skin cancer apps onto a general and
coarse-grained taxonomy of four categories (see Fig. 1 bottom left). These categories
were derived from a pre-survey of the literature without constraints. Google Scholar
was used to obtain a ¯rst taste of the landscape and directions in the literature. After
the removal of duplicates, some articles were excluded in both iterations if they did
not ful¯ll a set of inclusion criteria. The exclusion criteria are as follows: (1) the
article is non-English; (2) the focus is on a speci¯c aspect of smartphone use, such
as social networking; and (3) the target is skin cancer diagnosis with m-Health
technology rather than smartphone apps speci¯cally.
2.5. Data collection process
All included papers with their corresponding initial categories were compiled from
various sources to a single Excel ¯le to simplify the further steps in our analysis.
Several full-text readings resulted in a large collection of highlights and comments on
the surveyed works and a running classi¯cation of the articles into a re¯ned taxonomy. All comments were saved in the body of the texts (depending on each author’s
preferred style, either in hard or soft copy versions). The main ¯ndings were summarized, tabulated, and described. Sets of relevant information were saved in Word
and Excel ¯les, which include a full list of articles; their respective source databases;
summary and description tables; categorization tables based on medical specialties,
purposes, review sources, target platforms, and audiences; and various related
¯gures. These datasets are provided in the supplementary material as a complete
reference for the results described next.
3. Results
The initial query search resulted in 178 articles published in 2011–2016: 36 articles from
Science Direct, 101 from IEEE Xplore, and 41 from WoS. Only eight articles were
duplicates across all three libraries. After the scan of the titles and abstracts, 37 further
articles were excluded, thereby resulting in 133 papers. The full-text reading resulted in
the exclusion of 23 additional articles. The 110 articles in the ¯nal set were read thoroughly for developing a general map of the research conducted on this emerging topic.
Out of the 110 articles, 46 (41.81%) articles focussed on the development of
various AI algorithms and actual attempts to develop or design medical apps that aid
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Q. M. Yas et al.
in the prevention and early detection of MM. Twenty-eight (25.45%) articles
included analytical studies on the incidence of skin cancer, the classi¯cation of
malignant cancer or benign cancer, and the methods of prevention and diagnosis.
Twenty-two (20%, 22/110) articles consisted of studies that range from the evaluative or comparative study of apps to the exploration of the features desired for the
skin cancer detector process. Fourteen (12.72%) articles comprised reviews and
surveys that referred to actual apps or the literature that describes medical apps for a
speci¯c skin cancer or other diseases or provides a general overview of the technology.
We observed the aforementioned patterns, captured the general categories of
articles, and re¯ned the classi¯cation into the literature taxonomy, as shown in
Fig. 2. We distinguished several subcategories in the main classes, although overlaps
emerged. The following sections describe the observed categories and provide simple
accompanying statistics.
3.1. Development and design studies
Given the growing interest in the topic of skin cancer, we found that most of the
articles (46/110) involved the medical community and obtained some descriptive
statistics to understand this ¯eld. We ascertained that the largest percentage of
articles described the development and design of various methods and techniques
used to detect and diagnose skin cancer.
References 2, 5, 7, 8, 12, 24, 26, 29, 30, 42, 43, 46, 56, 57, 78, 79, 93 and 109 focussed
on diagnosis and detection using various techniques, such as skin cancer of epiluminescence microscopy and micro-machined millimeter-wave (mm-wave), in addition to those used for image segmentation in the diagnosis of skin cancer as either
melanoma or non-melanoma. The second largest proportion of articles described the
development and design of smartphone applications for skin cancer. References 28,
38, 40, 45, 51–55, and 85 reported that the disease is diagnosed by taking an image of
the area directly a®ected using a smartphone camera. These applications are platforms to help patients and physicians in the rapid detection of skin cancer instead of
waiting for traditional clinical detection. Few articles described the development of
some devices used in the detection of skin cancer in detail. References 3, 15, 18, 20,
23, 48, 50, 66, 83 and 93 stated that the devices are used in conjunction with a
computer-aided diagnosis (CAD) system as a platform to analyze the data sent by
the sensors for the detection of malignant tumors of the skin. References 87 and 105
presented an extensive study on the relationship between vitiligo skin cancers to
show how to detect skin cancer with this type of disease. References 97 and 108
showed an interest in some companies that have developed novel synthetic compounds and drugs, such as HDAC5, HDAC6, and 6 h, to treat skin cancer due to the
sudden rise of skin cancer incidence globally. Reference 64 provided a comprehensive
and systematic description of the risk of exposure to large amounts of ultraviolet
(UV) radiation among young adults, which can lead to skin cancer. Reference 72
1830003-6
Systematic Review on Smartphone Skin Cancer Apps
Method-based
Technique-based
Development and
design
AI classifier-based
Smartphone apps
Methodology-based
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Proposed framework
Analytical studies
Selection method-based
Classification method-based
Skin cancer reports
Articles of skin
cancer apps
Global pattern-based
m-Health app use
Evaluative and
comparative
Melanoma diagnostic approach
Disease status (malignant versus
benign)
General overview
Short review
Reviews and
surveys
Systematic review
Mini review
Review of m-Health
Fig. 2. Taxonomy of research literature on skin cancer apps.
referred to new strategies developed to overcome abnormal skin pigmentation. In
addition, this reference provided details on how complex facial defects caused by
non-melanoma skin cancer (NMSC) can be treated by applying a non-cultured
autologous epidermal cell (NCAEC) application to improve the color of aesthetically
displeasing areas caused by burn scars, melanocytic nevi, and vitiligo. However, Ref. 74
investigated the role of exogenous and endogenous cannabinoids in mouse skin
cancer, and the results con¯rmed the use of exogenous cannabinoids for the treatment
1830003-7
Q. M. Yas et al.
of melanoma but did not support the use of the endogenous cannabinoid system in the
pathogenesis of skin cancer. Reference 76 described a text intervention that is e®ective
in inducing signi¯cant improvement in sun protection to prevent skin cancer.
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3.2. Analytical studies
The second largest category of articles (28/110) comprised analytical studies that
attempted to classify various tumors that infect the skin.
References 1, 4, 11, 16, 27, 34, 36, 39, 44, 47, 96 and 99 provided a comprehensive
analysis of the various methods, classi¯cations, and tools used in the detection of skin
cancer. References 67, 92 and 101 analyzed NMSC and highlighted the importance of
regular care in terms of medical dermatology for the patient population and the
importance of periodic inspection for this type of skin cancer. References 60, 62
and 65 provided an analytical description of patients who are injured due to exposure
to UV and presented discretionary ratios for people with skin cancer in some
countries. References 88 and 90, on the causes of cancer, conducted a detailed analytical study on young people who use tobacco and indoor tanning beds and exposed
to UV radiation through outdoor sun tanning and work. References 88 and 90 helped
the participants achieve a signi¯cant reduction in tobacco use using a multi-pronged
comprehensive approach based on social norms and values for a long time; the
authors conducted a detailed analytical study on the causes of skin cancer. Young
people who use tobacco are commonly exposed to the risk of lung cancer when they
use tanning beds, which area source of UV radiation. Moreover, tanning bed users
may probably incur prolonged sun exposure, which further increases their skin cancer
risk. References 73 and 94 focussed on families with a history of melanoma, especially
the carriers of mutations in the CDKN2A gene or MC1R genotype that are considered a signi¯cant factor in the diagnosis and evaluation of the disease risk during
the developmental stages of a malignancy. Reference 21 focussed on the two-dimensional scanning resolution of a micro-machined mm-wave based on a combination of high resolution and high sensitivity, which is important for the diagnosis of
early-stage melanoma. Reference 81 showed that Erk and P38 play a crucial role in
the cancer-promoting e®ect of capsaicin on carcinogen-induced skin cancer in terms
of in°ammation and concluded that skin cancer patients must pay considerable
attention to their daily diet. Reference 82 discussed a variety of preventative measures speci¯c to women that can reduce the chance of being diagnosed with skin
cancer as well as current detection methods and future treatment options. Reference 91 presented an analytical study by the Cancer Institute of New South Wales on
public education regarding skin cancer and the role of mass media campaigns, which
were found to lead to a positive rate of return on the investment in terms of prevention in New South Wales, Australia. Reference 102 applied imaging cycle microscopy to analyze the immune contexture in human skin cancer by CD8 T
lymphocytes. Reference 107 applied microscopy imaging to analyze the immune
1830003-8
Systematic Review on Smartphone Skin Cancer Apps
contexture in human skin cancer cells and examined the possible e®ect of enzymes,
which may lead to cell damage and death in some cases.
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3.3. Evaluative and comparative studies
Several studies (22/110) on skin cancer apps have attempted to participate in the
new trend to evaluate and compare these apps and involved mostly professionals
from health-care disciplines.
References 9, 13, 25, 32, 33, 35 and 58 compared di®erent techniques and methods
for the classi¯cation of skin cancer according to local and global strategies for the
detection of melanomas using di®erent classi¯cation methods. References 41, 49
and 85 speci¯cally evaluated the m-Health system using smartphones, which are seen
as an innovative and convenient modality for providing medical consultations for
people with skin cancer. References 22 and 37 presented new devices for skin cancer
diagnosis: a micro-machined millimeter wave with a high-resolution microwave
measurement probe and a non-invasive based on a resonance microwave re°ectometry device. These imaging studies used an arti¯cial dielectric skin model to show the
possibility of obtaining a high contrast resolution for small cancerous tumors at the
early stage of skin cancer. References 59 and 95 used a logistic regression model to
evaluate the odds of NMSC after adjusting for skin type, sun exposure history, and
the indication of NSAID use. A di®erent focus was adopted by Ref. 61, which
evaluated how e®ectively HIV predisposes albinos to skin malignancies. This reference con¯rmed that albinos make poor use of free and available antiretroviral
therapy services provided by health-care centers. Reference 68 evaluated the impact
of early detection on the risk and prevention of skin cancer for golfers and golf course
workers. A comparative study was undertaken by Ref. 69 on the performance of
malignant skin lesions in the head and neck for basal cell carcinoma (BCC) and the
trunk for squamous cell carcinoma (SCC); dermato¯brosarcoma protuberans; skin
secondaries from the stomach, breast, and lung; mycosis fungoides; and MM to
compare the pattern of skin malignancies in Dammam Medical Complex in Saudi
Arabia with that in other parts of the world. Reference 89 presented the results of a
comparison of the tumor burden in trisomic mice for two groups of Ts1Rhr trisomic
mice (Ts mice) and euploid (WT mice). The use of the trisomic mouse model to study
the genetics of people with Down syndrome extends the understanding of the
mechanisms that underlie the protection against and susceptibility to di®erent forms
of cancer. Reference 100 evaluated the e®ect of indoor tanning for the majority of the
population based on their exposure to indoor tanning, especially young and middleaged people. This reference veri¯ed that indoor tanning is harmful to health regardless of the location; thus, the proliferation of indoor tanning devices in all
locations should be discouraged. Reference 103 presented an assessment of the cumulative incidence, tumor burden, and risk factors for skin cancer among patients
who had undergone a lung transplant.
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3.4. Reviews and surveys
The ¯nal and smallest set of articles (14/110) in our taxonomy consisted of reviews
and surveys of the literature about skin tumors and apps.
References 6, 10, 70 and 71 provided a review of the most important implementations of techniques and methods for the classi¯cation of skin cancer in the
detection of skin melanoma and non-melanoma. References 77, 80 and 104 were
speci¯cally considerably focussed on the issue of peripheral leukocyte telomere
length, skin physiology, and various surgical and non-surgical treatment modalities
available for the management of skin cancers associated with the risk of a cutaneous
melanoma and NMSC. References 63 and 106 reviewed the work on the link between
tanning bed use and skin cancer, speci¯cally the biological e®ects of UV radiation
exposure, which is associated with cutaneous malignancy and indoor tanning.
References 84 and 110 focussed on in-depth reviewing of the state-of-the-art
m-Health services and applications proposed by various developers. Reference 19
presented a short review of the experimental results and clinical experience acquired
in the auto°uorescence diagnosis of benign, dysplastic, and malignant skin neoplastic
tumors. Reference 75 presented a review of 101 melanoma reports from di®erent
laboratory specialists’ skin multidisciplinary team meetings, core data items, and free
text. Reference 98 conducted a systematic review and a meta-analysis of co®ee intake
level and the risk of MM by referring to cohort and case studies.
Figure 3 shows the relationship between the number of articles that have been
collected from the literature and the years of publication of those articles. The chart
illustrates a clear contrast to the number of studies presented on the subject of our
research. Therefore, consideration should be given on this contrast, notes outstanding to the target objective of this study should be extracted, and the study in
Fig. 3. Number of included articles in di®erent categories by year of publication.
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Systematic Review on Smartphone Skin Cancer Apps
this ¯eld should be expanded. The present research targeted three engines: IEEE,
Science Direct, and WoS, for basic research. These engines are the most reliable
sources of research. This study has adopted 110 articles from various sources: 56
articles from IEEE Xplore, 30 from Science Direct, and 24 from WoS. These sources
provided di®erent studies from various international journals, which included studies
on the applications and tools in skin cancer to help physicians and patients.
Figure 4 provides a breakdown of the four broad categories of our taxonomy by
the number of articles and database searched. This chart includes all articles dependent in this study. This chart shows a relationship between the sections of articles
and subdivisions within this study: development, design, review and survey, analysis,
evaluation, and comparison. A total of 110 articles were adopted from various
sources in this study. The chart presented varying proportions among these articles.
Forty-six articles are under the development and design category, 14 articles are
under the review and survey category, 28 articles are under the analysis category,
and 22 articles are under the evaluation and comparison category.
Figure 5 provides a clear picture of the distribution of subcategories within the
taxonomy based on the database searched. The taxonomy consists of three basic
sections: development and design; analysis, evaluation, and comparison; and review
and survey. This chart displays a ratio of varying studies used in this research
through subsections of titles in the taxonomy. These subsections represent the
direction for many future studies in this ¯eld. Accordingly, these studies may be a
starting point for many researchers in their future studies. The above-identi¯ed
subcategories could suggest directions for many future studies in the ¯eld of skin
cancer apps. These are discussed in more detail in the following section.
Fig. 4.
Number of included articles by main category of article and database source.
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25
21
20
13
12
8
Development & Design
Analytic
Evaluation &
Comparative
3
1
Mini-Review
1
Systematic review
Ganeral Overview
2
Short reviw
2
Disease status (malignant vs. benign)-based
Skin cancer reports
Classification-based
1
Selection method-based
Propos fremework
Methodology-based
Smartphone apps
AI classifier-based
Technique-based
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0
Method-based
1
Melanoma diagnostic approach
4
3
7
5
mHealth apps use
5
Global pattern-based
5
11
10
10
Review M-Health
15
Review & Survey
Fig. 5. Distribution of subcategories in the taxonomy.
4. Discussion
This study aims to provide an update on the infrastructure of skin cancer apps and
highlight research trends that deal with this topic. Our comprehensive survey
focusses on previous articles on the subject of skin cancer applications rather than the
applications themselves. In addition, we provide a taxonomy of articles related to
this topic to assist researchers.
A taxonomy developed based on the literature can provide several bene¯ts. A
taxonomy of published works imposes organization on a set of publications. A new
researcher who is interested in the trend of skin cancer apps may be overwhelmed by
the large number of publications written on the topic when no organizational
structure exists and fails to gain a proper sense of the actual activities in this ¯eld.
Various articles treat the topic from an introductory perspective, others examine a
selected number of existing apps, and some involve developing the actual apps.
Providing a taxonomy helps sort the di®erent works and activities collected from the
literature into a meaningful, manageable, and coherent framework. A taxonomy can
also provide researchers with important insights into a topic in several ways.
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First, a taxonomy can be used to identify potential directions of research in a
given subject. This work on the taxonomy of skin cancer apps a±rms that
researchers are interested in urging their peers and users to focus on this type of
application, which drives a new trend in this area. Other research paths identi¯ed in
this taxonomy include evaluating current apps or sharing the experience of developing actual apps. Secondly, a taxonomy allows researchers to detect gaps in the
literature on a particular subject. Mapping the works on skin cancer apps highlights
the weaknesses and strengths in the research coverage.
Regarding the articles reviewed in this study, the developed taxonomy shows that
some groups of individual apps receive signi¯cant attention in terms of review,
evaluation, and analysis, and considerable development e®orts in this ¯eld are based
on integrated solutions and frameworks in conjunction with the surveys of the literature based on an adequate representative sample. Our taxonomy highlights some
of the fundamental aspects of skin cancer apps, such as privacy and °exibility, which
have received considerable attention from researchers compared with traditional
technologies. Researchers working on an area of interest adopt a certain taxonomy
by developing a common language through which future works are shared and discussed. For example, for skin cancer apps, these works could take the form of a
development paper, a comparative study, or an overview.
The articles included in the review are discussed in the following sections to
conduct research on skin cancer applications that diagnose malignant tumors, the
challenges that users of this technology face, and some basic recommendations to
avoid these issues.
4.1. Motivations
Skin cancer detection applications used in the smartphones are considered a promising and important area of research. This section reports some of the characteristics
of the literature, which we grouped into categories according to certain bene¯ts based
on the references to aid further discussion, as shown in Fig. 6.
4.1.1. Motives related to skin cancer detector/diagnostics
The proposed WR-22 device has the potential to be used for fast tissue inspection
during surgery by specialist doctors.3 This device is easy to fabricate and provides a
low-cost solution for fast and accurate skin cancer detection. The THz tissue method
is an e±cient technique for the analysis in skin cancer diagnostics.4 This method has
a sub-picosecond resolution and provides information on the phase of the re°ected
signals by measuring short pulse re°ectance from the interfaces. Moreover, a CAD
system has been used to diagnose skin cancer, which ¯nds the location of a lesion, and
estimate the probability of the disease.6 The epiluminescence microscopy seven-point
checklist can be used to describe the malignancy of a lesion,8 which allows less
experienced observers to achieve high diagnostic accuracy. The automation of skin
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A new direction related to skin cancer
study/education
Benefits devices used to detection /diagnostics
•
•
•
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•
•
•
•
•
Easy and provides a low cost and fastdetection.
An efficient technique in diagnostic.
Identifies and estimates the probability of the
disease.
A high quality in diagnostic accuracy.
Substitute of the clinician indiagnosis.
A high resolution and highsensitivity.
A promising tool in detection.
Diagnosis method is better than other.
• Image classification and recognition
using Fourier transformation tool.
• Conduct a correct diagnosis using CADsystem.
• Image processing techniques are useful
in teaching physicians.
• The students benefit from the mobile
application
Skin Cancer
Smartphones
Apps Benefits
Benefits smartphone related to skin cancer
•
•
•
•
•
•
•
•
•
Fig. 6.
A new feature captured images.
Used to the management of the medical information.
Remote monitoring of patients in real-time.
Beneficial in the diagnosis in terms cost, time, and reliability.
A good clinical and educational tool.
Provide service integrated with the 3G network.
Used to assist diagnostic devices in underserved areas.
A strong impact on all health-care services.
An innovative and convenient modality for providing
dermatologic consultations.
Bene¯ts categories for smartphone applications based on skin cancer.
cancer detection is designed to reduce the false positive or false negative clinical
diagnosis by adding a quantitative observation to the clinical eye observation.”10
The automated skin cancer system is well suited as a substitute for the clinician in
melanoma diagnosis. The ¯nite-di®erence time-domain method is utilized to detect
local variations in the electrical properties of the skin tissue due to the presence of
anomalous cells.18 Using such method allows one to retrieve information about the
growth rate of possible melanomas and monitor the risk. Another work presented a
two-dimensional scanning resolution technique that combines high resolution and
high sensitivity, which are important for the diagnosis of small, early-stage skin
tumors.21 Dynamic thermal imaging with a properly standardized methodology has
been proposed and is considered a promising tool for detecting skin cancer.78 The
Roebuck SCAN tool was developed to identify and prevent skin cancer and meet the
educational needs of a state council of nurse practitioners.93 This tool is highly
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adaptable to di®erent populations who have various levels of clinical competency.
The real-time Raman spectroscopy method can be used for vivo (living body) skin
cancer diagnosis with the most conservative multivariate statistical methods in the
¯ngerprint region96 and is equivalent to or better than other diagnostic aids.
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4.1.2. Motives related to skin cancer apps
A new feature to capture color variation and border irregularity has been proposed
for smartphone-captured images.46 Smart mobile phones have been used in the
management of the medical information of patients, such as medical health record
access, appointment management, and prescription management, and this technology is considered acceptable.49 A new m-Health platform called C-SMART was
proposed for the remote monitoring of patients in real time.50 A mobile framework
for segmentation dermoscopy images to examine skin lesions through the Windows
phone and Android environments may be bene¯cial in the diagnosis of melanoma in
terms of cost, time, and reliability.51 A mobile-based system developed for Android
that uses by a supervised classi¯cation method allows the user to capture images
using a smartphone camera or load images from a mobile gallery for skin lesion
analysis.52 Mobile phone technology serves as a clinical and educational tool by
health-care providers and facilitates patient adherence to treatment and diagnostic
requirements.54 The mobile medical service model has been proposed to integrate
medical services with the 3G network. This model works as a new medical approach
with the traditional medical treatment and hospital management modes.55 Smartphones can be used to assist diagnostic devices in routine skin screening in underserved
areas and in developing countries, particularly in West Africa, where health-care
infrastructure is limited.56 m-Health applications can have a strong impact on all
health-care services, such as hospitals, care centers, and emergency services, especially
for the elderly, disabled, and chronically ill.84 Mobile teledermatology through cellular
phones is considered an innovative and convenient modality for providing
dermatologic consultations for skin cancer screening.86 Smartphone apps available
only for Apple users have been presented, which aim at minimizing the diagnostic
delay experienced by people with melanoma, which may be signi¯cantly associated
with mortality.110
4.1.3. Motives related to skin cancer study/education
The use of the Fourier transformation tool has been proposed for studying melanoma
lesions, given that it would be useful in image classi¯cation and melanoma image
recognition.1 The CAD system provides information, which allows dermatologists to
extract proper feature selection methods for making a correct diagnosis of melanoma.6 Image processing techniques can be used to distinguish melanoma from Clark
nevus lesions that are benign, which is useful for teaching physicians to di®erentiate
lesions.16 Being involved in the development of a mobile application was bene¯cial to
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students because they gain the opportunity to participate in real-world projects,
instead of only being onlookers.53
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4.2. Challenges
Skin cancer is a serious disease. Therefore, many developers and researchers have
attempted to ¯nd quick and easy solutions through the creation of applications to
help doctors and patients diagnose the disease early. However, the surveyed works
indicated that researchers are concerned about the many challenges associated with
skin cancer apps and their e®ectiveness in health care. The challenges reported for
skin cancer apps are discussed below along with the citations of the relevant references to which the reader can refer for the original suggestion on and the further
discussion of the challenges. The challenges are categorized into a few groups
according to their nature to aid discussion, as shown in Fig. 7.
4.2.1. Challenges related to biological e®ects
Biological e®ects can impede the diagnosis of skin tumors. The early detection of
melanoma is considered one of the greatest challenges faced in dermatological
practice8; the misclassi¯cation of melanoma and non-melanoma in situ suggests a
considerable overlap between the two categories of melanoma.16 However, the
standard biopsy could cause the dissemination of the cancer cells; thus, this procedure is not advisable in many cases, which includes some cutaneous neoplasties.19
The detection of early-stage tumors with a =10 characteristic surface size can
represent a signi¯cant challenge for raw images compared with others.37 However,
the most important risk factor for melanoma is the unprotected exposure to UV
radiation,40 and NSAID use was con¯rmed to be not associated with NMSC risk.
Consequently, the dose–response relationship with a long duration of NSAID use is
insigni¯cant.59 Several studies focussed on the association among tanning bed use
and skin cancer, the biological e®ects of UV radiation exposure, and UV burden,
which is considered a major reason for skin cancer.63,65,88,100
4.2.2. Challenges related to smartphone apps
The use of smartphone apps for medical purposes can have unwanted e®ects, many of
which have been highlighted in the literature. However, challenges related to the
apps exist. Reference 28 referred to creating a mobile melanoma detection application that was developed for the Android system only and is an Android Developer
Tool as opposed to a development tool for the Apple system, whereas Ref. 45 provided an app that can be employed only on the iPhone 4 device, although many
di®erent systems are used in various devices that are currently available in the
market. Smartphone images that are captured under loosely controlled conditions for
melanoma detection and image processing are often subject to computation and
memory constraints.46 Therefore, the researchers had to learn how to use APIs to
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Concerns on biological
effects
• Impend diagnosis
process.
• Lead to the overlap in
diagnosis.
• Could cause in
the dissemination
of cancer.
• Considered the
most risks
causing cancer.
• NSAID
used a
long
duration
insignificant.
• It considered a
major reason for
skin cancer.
Skin CancerSmartphone
Apps
Challenges
Concerns on reliability
• Loss of some
information from
lesion
• Shape.
• The classifiers
proposed still
insufficient for
the
discrimination.
• Segmentation
problems need
more
information.
• Lack of reliable
distribution of skin
• Types.
Concerns on education
• Medical education and healthcare are considered critical.
• Neglect some information referred in the theoretical study
• Sometimes provides misleading results
Concerns on patients
• Increased the number of injured.
• Lack of supportive care needs and psychological
health.
• Lack of knowledge of disease risk
• Lack of confidence and time constraints.
• The lung-transplant recipient more exposed to cancer.
• Reason for skin cancer.
Concerns on availability/services
• Lack of specialists.
• Lack of medical services.
• Sometimes normal patients exposed to the risk of cancer.
Concerns on medical history of patients
• Family history data can be inaccurate.
• May increase the number of moles and dysplastic nevi.
• The absence of data.
Concerns on smartphone apps
• Can have unwanted effects.
• Developed for the Android system only.
• Often subject to computation and memory constraints.
• Necessary save the data to an outside source.
• Limitations in the previous mobile technology.
• Related to the technical difficulties.
• It available only in English.
Concerns on tools/devices
•
•
•
•
•
Cannot be a substitute for the skillsof clinicians.
It affected in the electrical properties of the ski.
Regarding of the hardware and software design.
It has several drawbacks.
Reason for skin cancer.
Concerns on physicians/developers
• Difficulty visually differentiating between different
melanoma.
• Lack of information on how to use API.
• Low experience in the medical field.
Fig. 7. Challenges categories for smartphone applications based on skin cancer.
gather the necessary information and save such data to an outside source.53 Reference 55 identi¯ed some limitations in the previous mobile technology, in which the
quality of the synchronization of audio with video transmission in a moving environment has an impact on the quality of communication, which could be improved
by a variable transmission rate and good frequency utilization.55 The limitation of
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Ref. 86 relates to technical di±culties where a number of images were not transmitted instantaneously, which prevented mobile phones from capturing dermatoscopy images, despite the fact that another study that used the same technique was
able to improve diagnostic accuracy.86 However, the study referred to 39 apps that
are available only for Apple users for melanoma detection. Another limitation of the
study is that the apps were only available in English; therefore, the researchers may
have failed to identify apps that were published in other languages.110
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4.2.3. Challenges related to patients
The increase in patients with melanoma constitutes a major challenge in many
countries. Statistics have shown that a large number of individuals within a given
population have been diagnosed with melanoma, especially the white population,
and this trend continues to rise.41 Moreover, Ref. 57 raised awareness among healthcare professionals about the need for vigilance to identify the supportive care needs
and the psychological health of patients with NMSC. However, a signi¯cant proportion of patients with NMSC have unmet supportive care needs and have experienced heightened distress levels.57 Reference 61 validated that albinos make poor
use of free and available antiretroviral therapy services because they fear being easily
identi¯ed and considered a stigma by the community. However, this study has a
limitation due to the possible existence of a selection bias because the participation of
some of the patients was voluntary. Furthermore, clinical diagnoses are not always
con¯rmed histologically because some patients live outside of the targeted healthcare area.68 The lack of con¯dence and time constraints are issues that arise during a
patient visit for skin cancer examination. These issues lead to some barriers and a
practice gap.82 However, the weaknesses of this study include a relatively small
cohort of patients with a history of non-Hodgkin lymphoma (NHL). These patients
are subject to the high recurrence rates of BCC and SCC, even after using Mohs
micrographic surgery to remove one skin cancer layer and examining this layer under
a microscope immediately.95 Finally, limited studies corroborated that skin cancers
frequently occur in lung-transplant recipients. Therefore, the risk of subsequent skin
cancer is increased substantially in patients who develop skin cancer after their
transplantation.103
4.2.4. Challenges related to tools/devices
Various tools and devices have been proposed for helping physicians diagnose various
dermatology lesions. Computer accuracy has improved but cannot be a substitute for
the skills of clinicians or histopathology.6,7,70 In one automated method, the resonant
frequency in the sensors is signi¯cantly a®ected by the electrical properties of the
skin during the diagnosis of the disease.15 Major concerns exist in relation to the
design of the hardware and software of a system to reduce the platform overhead
with minimal user intervention and minimal cost.50 Due to the subjectivity of
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human interpretation in dermoscopy images for detection of melanoma, there has
been a growing interest in the development of automated systems to help clinical
diagnosis.”51 CAD systems for pigmented skin lesions have demonstrated good
performance diagnostically, but such systems cannot be used yet to provide the best
diagnostic results or replace the skills of clinicians or histopathology to prevent the
high recurrence rates of BCC and SCC, even after Mohs micrographic surgery.95
Laser-induced breakdown spectroscopy (LIBS) can be used as a surgical tool to
distinguish melanoma lesions. However, this tool has several drawbacks, such as
problems with the beam and detector position and space limitations, which must be
overcome before LIBS becomes suitable for practical use in the clinical setting.99
4.2.5. Challenges related to reliability
A key challenge in terms of reliability is that image segmentation approaches can
misclassify pixels as small white spots, which may lead to the neglect of the irregularity in the lesion shape, even though such irregularities are considered by dermatologists to include valuable information for performing manual segmentation.2,17,31
The overall performance of the proposed classi¯ers remains insu±cient for the
accurate discrimination of the combination of colors and textures that may lead to a
more optimal classi¯cation performance compared with a separate color and texture
features analysis.42 Segmentation problems need more information in one spectral
band compared with color images that have three spectral bands of color.44 Moreover, the absence of a reliable distribution of di®erent skin types in di®erent
populations and adjustment for skin color are also desired by dermatologists.60
4.2.6. Challenges related to education
Medical education and health care are considered major and pertinent issues when
talking about reliable mobile phone infrastructure, which could provide the ideal
framework for m-Health initiatives.54 A theoretical study pointed out that subsurface blood °ow causes an overall reduction in the performance of the frequencymodulated thermal wave imaging technique, which could be a limiting factor for the
diagnosis of small volume lesions. Therefore, researchers should not neglect this
aspect during the theoretical study of subsurface blood °ow, which often causes an
overall reduction in the performance of the detection of the disease.58 Observational
studies can sometimes produce misleading results regarding the connection between
tanning bed use and melanoma and thus present erroneous results.106
4.2.7. Challenges related to physicians/developers
Many physicians and developers interested in health care have highlighted the
problems in diagnosing various forms of skin tumor. Physicians have di±culty
visually di®erentiating between melanoma and Clark nevus lesions, which are
benign.26 However, the challenges faced by developers depend on the platform they
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use when implementing the use of an API because they have to learn how to use APIs
to gather the necessary information and save such data to an outside source.53
Reference 79 proposed a CAD system that can be e®ectively used to diagnose skin
cancer accurately. This tool is substantially useful for rural areas, because experts in
this medical ¯eld may not be available.79
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4.2.8. Challenges related to availability/services
Health-care services face some challenges because of the lack of specialists working in
the ¯eld of melanoma detection. Therefore, the use of free and available antiretroviral therapy services for albinos is poor.61 The lack of medical services for the
diagnosis of skin cancer in remote areas in poor and developing countries presents a
great challenge in terms of the availability and e±cacy of health-care services.83
Dermatology patients presenting for regular care are often exposed to the risk of skin
cancer.101
4.2.9. Challenges related to medical history of patients
Knowing the medical history of a person and their family is crucial in the diagnosis of
tumors in some patients with skin cancer. The absence of a family history for the
evaluation of skin cancer cannot be replaced by objective methods. Moreover, some
self-reports of family history data can be inaccurate,73 but the number of moles and a
typical or dysplastic nevi may increase because of the personal or family history of
melanoma and exposure to UV radiation. The risk of skin cancer can increase90 in the
absence of data. Assumed historical trends in melanoma can be a reasonable proxy
for future cases of melanoma and NMSC.91 However, the weaknesses of this study
include a relatively small cohort of patients with a history of NHL who are subject to
high recurrence rates of BCC and SCC, even after Mohs micrographic surgery.95
5. Recommendations
We brie°y provide some recommendations from the literature that aim to mitigate
the challenges faced by developers, physicians, designers, and patients and simplify
ways to achieve accurate diagnosis and prevent the occurrence of various skin cancers, as shown in Fig. 8.
5.1. Recommendations to developers
Many of the recommendations must be followed by developers because the development of di®erent systems and devices helps patients and physicians alike. They
can introduce further improvements using a segmentation process based on classi¯cation methods, such as the well-known support vector machine, which can be
merged with the proposed segmentation approach through a majority voting system.2 The re¯nement of current approaches and the development of new techniques
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Recommendations to physicians
Recommendations to developers
• Using automated system.
• Adapt Otsu segmentation and
Canny edge
• Using micro machined
millimeter-wave
• Using genes for discriminating.
• Using a new computerized
framework.
• Reliance on Early detection is
vital.
• Provide appropriate
treatment by health-care
teams
• Provide necessary training
• Clinical diagnosis is important
• Adapt improvements of the
segmentation process.
• Development a new techniques.
• Reliance on the automated systems.
• Using the pigment network
• Encouraging collaboration.
• Using a smartphone camera.
• Conducting research and
developing applications,
• Maintaining data privacy and security
Recommendations to preventive
instructions
• Protect from exposure to UV radiation.
• Propose a novel smartphone called
SKINaid.
• Undergo a periodic examination of the
skin.
• Must pay attention to their daily diet.
• Follow prompt care and
appropriate management.
• Periodic follow-ups by physicians.
• Validating the utility and safety of the
apps.
Skin Cancer
Smartphones
Apps Benefits
Recommendations to designers
Recommendations to patients
• Needs to ascertain
design and analysis
procedures.
• Improving the preprocessing.
• Adapt to classification
system using shape
descriptors.
• Focus on pigment network
analysis.
• M-health applications
should be designed based
on the knowledgegained.
• Use of mixed methods.
• Use a high-speed motor miniature
ultrasonic.
• Use new types of silicon-based sample.
• Using the numerical processing of
the raw images.
• Using sophisticated biomedical
imaging applications on
smartphones.
• Using a mobile medical application
server model.
• Using a nanotechnology.
• Using the NCAEC application
• Computer-aided diagnosis is userfriendly and robust.
• M-Health involves the
intelligent monitoring.
Fig. 8. Recommendations categories for smartphone applications based on skin cancer.
help in improving the ability to diagnose skin cancer and in achieving a signi¯cant
reduction in the melanoma mortality rate.6
Classi¯cation methods play a signi¯cant role in building and developing reliable
automated systems for the diagnosis of skin lesions.10 For example, the development
of the curvelet and using other methods can increase the accuracy of classi¯cation
results.32 Furthermore, the accuracy of classi¯cation could be improved by
extracting novel features using the pigment network.39,40,46 Therefore, encouraging
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nationwide collaboration is necessary for the full development of the C-SMART
platform, which enables the optimal sharing of medical databases and medical
applications among authorized medical sta® or patients and their family members.50
Developing a version of a skin cancer detection application using a smartphone
camera, allowing doctors to test this application on real patients and input, and
determining whether they agree with the automatic analysis are important.52
Moreover, conducting research and developing applications that aim to bring the
technology to underserved populations is bene¯cial to students who can participate
in the real-world projects.53 Reference 68 conducted an awareness-raising campaign
speci¯cally for golfers and golf course workers who are a key target population in
the prevention of skin cancer. One key factor in the success of the campaign was the
fact that such campaign was carried out at the site of risky behavior. Another factor
was the development of a multi-component intervention model that included innovative techniques and a motivational strategy.68 Moreover, the development and
testing of pigmented skin lesion classi¯cation systems through the creation of a
benchmark data set are of utmost importance.70 Maintaining data privacy and
security is, hence, a major issue in information management for patients and health
professionals.84
5.2. Recommendations to physicians
Physicians are considered a critical component in the treatment and diagnosis of
various diseases, particularly dermatological lesions. Inexperienced dermatologists
often use an automated system that helps them make highly accurate diagnosis.8
Otsu segmentation and Canny edge detection are considered the best approaches to
support physicians in the diagnosis and detection of melanoma.17 Reference 21
presented a micro-machined millimeter-wave near-¯eld probe that combines high
resolution and high sensitivity, which are important for the diagnosis of small, early
stage skin tumors. The micro-machined tapered-tip probe has a two-dimensional
scanning resolution as small as 1/6 m of the medium-normalized wavelength.21
Moreover, tests support the generalization ability of classi¯ers using the genes presented for discriminating malignant from benign samples,25,27 and clinicians depend
on the new computerized framework to automatically extract and measure the ¯ve
features from skin lesions and accurately classify them as benign or malignant.34
Early detection is vital, especially concerning melanoma, because surgical excision is
the only life-saving method for patients with skin cancer.41 Health-care teams provide appropriate treatment, which can make a di®erence in the lives of patients
during the treatment of skin malignancy by recognizing patient needs and related
cancer concerns.57,92 Training facial surgeons and dermatologists to o®er HIV
treatment services, especially to albinos, is necessary.61 Clinical diagnosis is important at high sensitivity to reduce unnecessary biopsies, which can be readily used for
the diagnosis of other types of cancer.96 The skills of dermatologists must also be
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improved with continued attention given to value-driven dermatologic care, which
can motivate through improved patient outcomes and ¯nancial sustainability.101
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5.3. Recommendations to designers/developers
Designers provide various necessary solutions that help physicians and users overcome technical problems encountered using various medical devices. A good designer
needs to ascertain which design features and analysis procedures are likely to lead to
a good model.7 Improving the pre-processing and processing parts of the automatic
removal of the black frame using reaction-di®usion cellular neural networks and
cellular automata makes hair wire removal e±cient for signature extraction using
natural computing and for the location of useful genes to eliminate artifacts.24
The classi¯cation system using shape descriptors is fairly robust to a change in the
segmentation method. Enriching these shape descriptors with the best set of texture
and color features is thus interesting and can be applied to larger databases.31
Accordingly, designers should focus on pigment network analysis to extract new
e±cient features and test the system with a di®erent large data set.35 Moreover,
m-Health applications should be designed based on the knowledge gained, which
allows the model to ¯ll the gap between the intention to use an m-Health application
and the actual usage of m-Health applications in the medical domain.49 However, the
optimal design for any project depends on the use of mixed methods to provide
the most complete and useful information during the planning stage and to manage
the time, money, and expertise needed for the project.64 The design of a high-speed
miniature ultrasonic motor that can be used in handheld mode that is integrated
with a photoacoustic and ultrasound imaging system modality would hence be useful
to visualize the multiple features of melanoma.109
5.4. Recommendations to patients
Many patients with di®erent kinds of skin cancer need considerable advice and
recommendations that can direct them to follow safe and healthy practices in their
daily lives. Advanced algorithm classi¯cations are applied together with intensive
tests on THz images of skin cancer.11 The potential uses of the systems in biomedical
approaches aim toward cancer therapy in vivo.14 New types of silicon-based sample
can be used, which can be tailor-made to mimic the dielectric properties of the tissue
of di®erent water contents and remain stable over the long term.32 The accuracy of
tissue discrimination can be substantially enhanced using the numerical processing of
the raw images based on correlation algorithms that facilitate a transition from the
proposed technique to clinical practice.37 Using sophisticated biomedical imaging
applications on smartphones has advantages, such as portability and low cost;
therefore, these applications can have a signi¯cant impact on health-care delivery as
assistive devices in underserved and remote areas.45,56 The methodology and techniques presented in Ref. 47 are useful and e±cient in the domain of classi¯cation and
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feature selection for various diseases. This research is devoted to applying this
methodology to the analysis of microarray gene expression data to ¯nd the most
important descriptive genes for investigating the disease. This approach is a part of a
very intense domain — bioinformatics.47 However, the mobile medical application
server model, which is for intelligent terminals under the 3G network environment,
provides customers with a quick and convenient medical treatment and health information consulting service by analyzing the characteristics of the existing mobile
network and the current development of mobile medical treatment. This model
works perfectly with a system and achieves interoperability with the hospital management system.55 Computing phase information is presented to transform raw
thermograms into phasegrams; the merit of this imaging method is the clear di®erentiation of di®erent melanoma stages58 while using nanotechnology, which provides
an exceptional opportunity on the molecular scale through a speci¯c interaction with
cancer cells and the inhibition of their function with several formulations used in
medical practice, which have become the standard for care.71 Using the NCAEC
application for secondary aesthetic improvement in complex facial defects is a concise
and proven method.72 Multimedia text messages are more °exible compared with an
SMS program design, which allows participant input into new program features.76
CAD is user-friendly and robust for images acquired in any condition and can facilitate the automatic diagnosis of skin cancer.79 m-Health, which involves the intelligent monitoring of patients, can lead to improved health outcomes and lowered
health-care costs85; thus, the widespread use of cellular phones and the expansion of
wireless networks lead to meaningful integration and innovative telemedicine.86
5.5. Recommendations on preventive instructions
One of the most important aspects in maintaining human health is the prevention of
widespread diseases around the world, which can be achieved by following instructions and recommendations. Unprotected exposure to UV radiation and consuming
certain foods are considered the most important risk factors for skin cancer. Reference 38 proposed a novel smartphone-based virtual reality system named SKINaid to
help in skin cancer prevention and pain treatment. The study used image processing
techniques that focussed on identifying/classifying the food items in the prevention
stage38; the potential chemoprevention e®ects of NSAIDs should be considered for
subjects with a prior history of NMSC.59 Avoiding UV radiation is also necessary,
given its potential to reduce the incidence of skin cancer, particularly in the fairskinned population.60,65 Therefore, health-care providers must educate parents on
the risks of indoor tanning and encourage parental contribution to discussions on
tanning bed avoidance.63,106 Patients must undergo a periodic examination of the
skin, and various clinical and environmental factors must be assessed as part of the
follow-up in transplant recipients.67 Skin cancer patients must also pay attention to
their daily diet and sun exposure and exercise the close surveillance of these
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Systematic Review on Smartphone Skin Cancer Apps
factors.81,82,87,100 For prompt care and appropriate management, frequent follow-ups
are necessary to decrease the chance of recurrence and the possibility of subsequent
metastasis in NMSC patients.95 The preventive aspect is covered in Ref. 103, which
advocates educating the infected persons about UV protection and the importance of
self-examination of the skin and periodic follow-ups by physicians to aid the early
detection of skin cancers, especially among patients with a lung transplant.103
Patients with malignant skin cancers should also be managed in a multi-disciplinary
setting, which has a plastic and reconstructive surgeon, a dermatologist, an oncologist, and a histopathologist with particular expertise in dermatopathology.104
Validating the utility and safety of the apps used by clinicians are important
in providing information to educate their patients and their potential usefulness for
melanoma detection.110
6. A New Research Direction
With the exception of the 110 papers reviewed earlier, the new direction of this
research will be described in this section. The supporting reviews are presented as
follows.
The health-care system primarily uses the Internet to facilitate the remote exchange of digital medical images and information among hospitals and clinics, as well
as to provide e-health services to patients.111–119 Medical information systems o®er
vital information, including complex data sets, such as medical annotations, clinical
examinations, diagnoses, doctor’s ¯ndings and opinions, and prescriptions with
scanned images related to the clinical examinations of patients.120 Digital medical
images, e.g., ultrasound, computed tomography (CT), electrocardiography (ECG),
magnetic resonance imaging (MRI), X-ray, and skin cancer images, are fundamental
to the diagnosis and treatment of various diseases. Therefore, ensuring security in the
storage, transmission, processing, and analysis of medical images without violating
the code of ethics for health information professionals is vital,121 given that the risks
of protecting medical information increase, particularly over the Internet.122–127 This
condition imposes three mandatory characteristics: con¯dentiality, reliability, and
availability. Another key requirement is that a medical image should not undergo
any degradation that will a®ect diagnosis based on the image. In general, medical
images must remain intact, without any visible alteration from their original form, to
ful¯ll this requirement. To achieve the aforementioned objectives, health authorities
and information security experts direct considerable attention toward the use of
information concealed either by digital watermarking or steganography in medical
images as a technique to enhance data security, image ¯delity, authenticity, and
content veri¯cation in e-health environments, where images are stored, retrieved,
and transmitted electronically.128 A key objective of information concealment either
by watermarking or by steganography is to embed data into di®erent multimedia
¯les, including image, audio, video, and text formats.129–1
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2
The embedded information can include data regarding hospitals, patient records,
and diagnostic information, among others.
The watermarking or steganography of medical images requires more care than
that of other image types. Unlike in natural image watermarking or steganography,
distortion is unacceptable in medical images because even a slight change may
mislead forensic pathologists. That is, when additional information is embedded into
medical images, such information should not a®ect image quality.163,164 Accordingly,
appropriate techniques should be established to achieve a trade-o® between payload
and imperceptibility,127,165–167 thereby allowing clinical diagnosis to be performed
properly on watermarked or stenographic medical images.168 Several important
constraints should be satis¯ed in dealing with the watermarking or steganography of
medical images. When information is embedded into the host image, distortion is
generated. Such distortion is highly undesirable in medical applications, in which
even a small distortion in an image, such as an MRI or X-ray image, may a®ect the
diagnosis of a physician. Accordingly, information should not only be extracted from
the image, but the original image should also be restored completely. Reversible
watermarking or steganography satis¯es the aforementioned requirement. This
technique can restore the exact state of the original image. An e®ective means to
embed information into a medical image is to de¯ne a region of interest (ROI), which
contains important information and should be stored without any distortion.169
Therefore, medical images typically comprise an ROI and a region of non-interest
(RONI). The ROI sections of an image include signi¯cant information for diagnosis
and thus should remain intact during the embedding process. The remaining sections
of an image are called RONI. Concealed information may be embedded into such
sections.170,171
Our critical review of information concealment presents watermarking and
stenographic approaches for medical images. However, these approaches focus on
X-ray, ECG signals, CT scan, MRI (shoulder), CT (abdomen), MRI (knee), broadcast
printing, ¯ngerprinting, scanning electron microscopy, and radar images.127,168–178
This condition results in the incomplete coverage of the watermarking area for medical
images. To date, no particular study on any type of skin cancer images, either taken
from a hospital setting or based on Smartphone apps, is available.
To perform such study, the segmentation of the ROI from skin cancer images is
vital as the ¯rst step in medical image analysis (MIA) because the error resulting
from segmentation is transferred to later MIA steps. This task is considered di±cult
due to the complexity of the involved anatomical features. The ROI may not be
separated from its surroundings because of gray-level inconsistency and the absence
of sharp edges along its border.179 This condition generates distortion in the image
after watermarking. Therefore, an appropriate segmentation method is necessary.
The most suitable segmentation method that can be used is the application of skin
detectors, given that skin pixels comprise the background of skin cancer images.
However, the segmentation of a colored skin image remains the most di±cult image
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Systematic Review on Smartphone Skin Cancer Apps
processing task in many applications, such as in pornographic image ¯ltering,180–184
face detection,185 human motion analysis,186 and watermarking and steganography.188–190 Moreover, skin detectors are di±cult to apply in skin cancer cases187
because skin color and skin-like color objects, such as hair, presented in a captured
image become uncontrolled and pose problems for skin detectors.191 Consequently,
skin detection may involve errors, and false detection occurs due to the failure to
identify non-skin objects with skin-like color pixels.192 Another challenge originates
from the fact that the appearance of skin color in an image depends primarily on
lighting conditions to provide the geometry of illumination and color at the time an
image is captured.193 Maintaining color consistency is yet another problem and a
major challenge in skin detection.194 Color should be presented invariantly or at least
in a manner that is insensitive to changes in lighting conditions. That is, the choice of
color space signi¯cantly a®ects the performance of any skin detector and its sensitivity to changes in lighting conditions. 195 Therefore, appropriate techniques for
solving skin detection problems are necessary, given that the ROI, which contains
sensitive information, should be avoided when embedding a watermark to maintain
image quality. Image segmentation should be performed properly to obtain the
determinant characteristics of a disease or a subsequent lesion.
7. Limitations
The most pertinent limitation of this survey is the number and identity of the source
databases, although the selected sources are a good and broad representative
collection. Moreover, the fast progress in this ¯eld hardly allows for any timeliness in
a survey. Furthermore, the fact that a snapshot of the research activity on this vital
trend of skin cancer apps does not necessarily reveal the reality of app use or impact
re°ects the response of the research community to the trend, which is the main
objective of this study.
8. Conclusions
The provision of adequate health care for patients with skin cancer has become a
global concern. Skin cancer is the most dangerous type of cancer and is widespread
among people because of the late diagnosis of the disease and the excessive exposure
to UV radiation by fair-skinned individuals. Research on the trend of using a
smartphone app to detect skin cancer is already active. Therefore, insights into this
emerging ¯eld are needed. This article aimed to contribute such insights through
surveying and taxonomizing the literature. Speci¯c patterns were identi¯ed from the
studies on skin cancer apps, and these works were roughly classi¯ed into four distinct
research categories: development and design, analytical studies, evaluative and
comparative studies, and reviews and surveys. Research studies on the attempts to
develop skin cancer app development and broad framework proposals also exist.
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Some domains have received more attention compared with others from researchers
(e.g., public health), and some functions have been of great or less interest (e.g., health
reference materials). These domains and functions re°ect the type of articles on the
topic of skin cancer apps, but give a clear indication about the gaps in this ¯eld in
terms of development and evaluation. Researchers have described the challenges they
have faced, and many have made recommendations in resolving the existing and
anticipated challenges, the list of which opens up many opportunities for further
research in this ¯eld. Other researchers have proposed that some studies should
initially focus on the functional aspects of the technology (the usefulness of medical
apps) and leave the non-functional requirements (e.g., preventive strategies) at a
later stage. Additionally, the new direction of this research has been explained.
Currently, no fastidious study presents watermarking and stenographic approaches
for any type of skin cancer images based on Smartphone apps.
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