The not-so-full body skin examination

By Warren R. Heymann, MD, FAAD
April 16, 2025
Vol. 7, No. 15

It is not my imagination. With every passing year, an increasing number of new patients schedule an appointment for a full (or total) body skin examination (FBSE, TBSE) to be checked (or, as some patients say, “scanned”) for skin cancer (keratinocyte carcinoma, melanoma, Merkel cell carcinoma, or others). I cannot fathom the number of FBSEs I perform daily on follow-up patients with a history of cutaneous malignancy.

My perception was confirmed as reality by Nowakowska et al. The authors evaluated 9,679,601 dermatology encounters in 1,207,619 patients. TBSEs comprised 63% of dermatology visits in Medicare patients aged ≥65 years, and the proportion of dermatology encounters that included TBSEs significantly increased from 53.1% in 2009 to 73% in 2018. Compared to visits where a TBSE was not performed, TBSE encounters had a higher proportion of patients who were male (48.7 vs. 44.0%), were younger (mean age = 76.2 vs. 76.9 years) and had a history of skin cancer (67.8 vs 54.8%) and actinic keratosis (81.8 vs 75.3%; all P < .0001). The authors raise important questions regarding the appropriateness of TBSEs, although their study did not address them. Are we over-diagnosing skin cancers that otherwise would not have caused any harm? Are TBSEs a proper use of a dermatologist’s time? Is the TBSE worth the societal economic cost? (1) These are critical questions, each deserving their own commentary.

As stated on the JAMA Patient Page devoted to screening and prevention of skin cancer, “In the case of skin cancer screening, experts are still unclear about whether or not the pros outweigh the cons.” (2) The updated evidence report and systematic review for the U.S. Preventive Services Task Force concluded, “Evidence is inconsistent regarding whether clinician skin examination is associated with thinner melanoma lesions at detection.” (3) Please see the AAD’s recent statement regarding the USPSTF recommendations. I concur with the AAD’s viewpoint.

Although voluminous literature abounds on cutting-edge techniques for evaluating cutaneous malignancies (confocal microscopy, optical coherence tomography, gene expression profiling, PRAME immunohistochemistry, etc.), optimal skin cancer screening begins with patient awareness and skin self-examination. Dermatologists routinely use clinical inspection complemented by dermoscopy throughout the day. Regarding total body photography (TBP), Rojas et al. state, “Based on an AAD consensus, TBP is recommended for individuals with familial atypical mole and melanoma syndrome, dysplastic nevus syndrome, or >50 nevi and at least 1 of the following: personal history of multiple melanomas, amelanotic melanoma, multiple pink nevi, multiple clinically atypical nevi, or a genetic syndrome predisposing them to melanoma. TBP with sequential digital dermoscopy is recommended for the evaluation of clinically atypical nevi. TBP is not recommended for children.” (4)

No established standardized routine for conducting FBSEs currently exists. (5) My approach has become so ingrained that I cannot remember the last time I thought about how I go about it. Each of us performs a FBSE slightly differently. Patients who receive a gown are instructed to get undressed to their comfort level. The medical assistant explains that the more I see, the better off they are. A chaperone is always present during my exam, which is especially important when examining women and children. My routine is to start at the top and work my way down (scalp, head, neck, chest, arms, hands, back, legs, feet (including toe web spaces), buttocks/perianal region, and male genitalia (with permission). Skin folds need to be separated in patients with an elevated BMI. I do not examine the vaginal region on a FBSE unless the woman has a specific area of concern. Most women will see a gynecologist periodically; however, men only see a urologist if there is a problem — this may be the only opportunity for such an examination. I ask patients to avoid pointing out lesions at other body sites during my exam, inviting them to tell me about them when I get to that particular body part. (I am distracted when I am told about a leg lesion while examining the face.) In my experience, another area that is often inadequately evaluated are nails, when adorned with nail tips or polish. I will remind patients to look for any unusual, pigmented streaks when they can do so.

Please see the image for an example of an optimal TBSE established after analyzing time efficiency, missed body parts, and movements by the patient and physician. (6)

In a survey of 140 members of the Canadian Dermatology Association regarding FBSEs, the majority of respondents were females (60%, n = 84/140), dermatologists (87.9%, n = 123/140), practicing in outpatient private clinics (62.1%, n = 87/140), and with over 20 years of practice (38.6%, 54/140). Most respondents (53.6%, n = 75/140) used gowns during FBSE, and 85.7% (n = 120/140) had both the patient and themselves move during the examination. Most respondents either spent 2-3 minutes (22.9%, n = 32/140) or 3-4 minutes (24.3%, n = 34/140) on performing FBSE, while 95.7% (n = 134/140) of respondents reported using a tool during the FBSE. Female respondents reported examining the breasts more frequently than their male counterparts (P = .004). Male respondents were significantly more likely to use a chaperone for the genital and breast examinations (P < .001). Specific anatomical sites were either “never examined” or “rarely examined” by the respondents: perianal (53.6%, n = 75/140), gingiva (52.9%, n = 74/140), oral mucosa (43.6%, n = 61/140), external genitalia (42.9%, n = 60/140), and between toes (30.0%, n = 42/140). (5)

A survey of 237 Fellows of the Australasian College of Dermatologists revealed that most Australian dermatologists do not routinely examine breasts or oral mucosal or anogenital sites as part of an FBSE. The anogenital region was the least often examined concealed site (4.6%), and 59.9, 32.9, and 14.3% reported always examining the scalp, breasts, and oral mucosa, respectively. In their conclusion, Pham et al state, “Emphasis should be made on identifying individual patient risk factors and education regarding self-examination of sensitive sites. A consensus approach to the conduct of the FSE, including concealed sites, is needed to better delineate clinician responsibilities and address medicolegal implications.” (7)

In their excellent discussion of the ethics of chaperoning during FBSE, Grandhi and Grant-Kels offer this bottom line: "Patients’ and practitioners’ comfort during intimate examinations such as FBSE is essential to patient-physician trust and quality of care. The option of chaperones should be made available to patients if they are uncomfortable being examined by someone of the opposite sex despite the fact that male chaperones may be hard to find in some office settings. Furthermore, conversations with the patient to address concerns of vulnerability should be undertaken so that a professional relationship in a safe environment can be established between the patient and the provider.” (8)

In his outstanding DWI&I commentary, “Epidemic of melanoma or epidemic of scrutiny?”, Jason Lee concluded, “Deadly forms of melanoma are real. Overdiagnosis of melanoma is real. A shift in strategy in melanoma detection is needed to close the gap on overdiagnosis.” (9)

Almost 20 years ago, Weatherhead and Lawrence asked this question about melanoma screening clinics — “Are we detecting more melanomas or reassuring the worried well?” (10) The answer is both. Until the time comes when artificial intelligence performs a FBSE (imagine a screening device akin to the TSA screen at the airport), FBSEs will occupy a substantial portion of a general dermatologist’s day. There is a pressing need to question the appropriateness of their value and cost to society. The fact is that it is the rare patient who truly gets a FBSE by dermatologists — we must partner with our patients and other practitioners to be sure that no areas are unexamined by a combination of self-examination and the assessment of others (hairdressers, dentists, ophthalmologists, and gynecologists).

Point to Remember: Full body skin examinations (FBSEs) are an increasing component of daily practice. The term “full” is often a misnomer. The issues of appropriateness and societal cost of FBSEs need further scrutiny.

Our experts’ viewpoints

Jane M. Grant-Kels, MD, FAAD
Dermatology Department, University of Connecticut
Dermatology Department, University of Florida

Full body skin examinations are part of the purview of a dermatologic exam. Since this involves examination of sensitive or “intimate” areas, there are many ethical issues to consider.

Is screening patients with a FBSE ethical and respectful of distributive justice?

Yes! Skin cancer is on the rise and about 15,000 patients die of squamous cell carcinoma per year, twice the number who die of melanoma. Furthermore, the controversy regarding whether there is overdiagnosis of melanoma is, in my opinion, “hype.” Our expertise with the dermatoscope, new technology (as reflectance confocal microscopy, optical coherence tomography, genomic testing, artificial intelligence applications, etc.) and the use of immunohistochemical stains in dermatopathology laboratories has increased our ability to diagnose melanoma and other skin cancers earlier affording us the chance to treat our patients’ skin cancers earlier, reducing morbidity and saving lives! (11-13)

How do we ethically deal with our disabled patients who need a FBSE?

Time during a busy clinic day is a precious commodity, especially because we are generally overbooked with patients, the waiting list of patients who need an appointment is growing ever longer, and we are asked to see more patients per hour than we have had to do in the past. Disabled patients (either physically, mentally, or psychologically) require extra time. Longer appointments, early in the day before our regular day starts or appointments at the end of the day would provide us the needed additional time to take care of these vulnerable patients. A New York Times article reported on the growing trend of doctors not wanting to take care of these time-consuming patients. We can do better! (14-16)

How do we ethically navigate patients who refuse a FBSE due to past emotional or physical trauma?

On occasion patients, even high-risk patients, refuse a FBSE. Often the reason is that they do not have the time, do not appreciate their risk, abide by religious standards not allowing this type of exam, and/or are embarrassed or shy. However, we need to be sensitive that on occasion this refusal is from patients who have suffered either emotional or physical abuse in the past. Dismissing them and not performing a FBSE may be the most expeditious route but is not the appropriate choice. Trying to engage that patient and make them feel safe will often ultimately afford them the opportunity to share their concerns with you. As their sense of safety and security in your office grows, most patients will eventually allow you to examine them. This may take more than one visit so rather than dismissing the patient and moving on, ask them to return for a follow up visit when you may have more time can be a helpful strategy. (17)

What are the ethical implications of the use of a chaperone?

Some institutions or practices mandate a chaperone for what is deemed an “intimate” exam. Since FBSE include breast and genital skin, it falls into that category. Why would a patient refuse a chaperone? Shyness or loss of privacy with a third-party present are the usual reasons. On the other hand, chaperones that are the same sex as the patient have been demonstrated to make some patients feel safer. Chaperones can also be protective of the physician as they are a witness to the encounter in the rare case a sinister patient is inappropriately litigious. Patients should be offered a chaperone so that they have a sense of control over their environment and feel safe. Where mandated, if a patient refuses a chaperone, limit the exam to avoid sensitive areas and document your chart as to why. (8,18)

Jeffrey J. Miller, MD, FAAD
Professor and Chair of Dermatology
PennState Health and College of Medicine

On a societal impact level, the FBSE may not provide value. On a personal level, the FBSE does provide value.

Let’s think about the societal impact level. The FBSE is a screening tool for skin cancer. As Dr. Heymann cites the often-referenced U.S. Preventive Services Task Force, the skin exam lacks credible scientific basis regarding thinner melanoma detection (though the USPSTF is not, as the AAD statement notes, judging the value of population screening by dermatologists). Yet we know that detecting skin cancer at an earlier stage leads to better outcomes, especially with melanoma. We also know that FBSE helps identify risk factors that increase likelihood of skin cancer (e.g. multiple atypical moles). However, here are key issues that involve value and societal cost:

Does the FBSE lead to improved health outcomes?

Does supply meet demand (consider the time it takes to get an appointment with a dermatologist)?

Does the variability in our technique impact reliability to detect a high proportion of early skin cancer?

I agree with Dr. Heymann — we need to target the at-risk population for the FBSE and determine the appropriate interval of skin checks. I also think we have an opportunity to teach a standardized approach to the FBSE in medical school and to partner with primary care clinicians to meet the demand for FBSE.

Let’s think about the value on the personal level. The FBSE, especially when done with proper lighting and proper exam table, along with a disciplined approach, creates trust between the patient and the clinician. The FBSE enables the dermatologist to connect with patients and reassure them that they do not have skin cancer. The FBSE adds to the patient story because the skin tells a story. To deliver on quality and safety, the FBSE requires effort and commitment. I remember when I missed a melanoma on a patient’s flank. I was moving too quickly through my FBSE. That memory motivates me to be there for the patient, who is not tired and is anxiously awaiting the outcome of the FBSE. The FBSE is our “stethoscope.”

Imagine posting the following sign at your dermatology practice: WE ARE NO LONGER PERFORMING FULL BODY SKIN EXAMS DUE TO LACK OF PROVEN BENEFIT TO YOUR HEALTH. For me, I will continue to be a critical reviewer of the data on the value of the FBSE AND I will continue to honor the importance of the FBSE for our patients.

Another viewpoint

The squeeze of the FBSEs: An academic department perspective
(Viewpoint added July 31, 2025)

Lindsay C. Strowd, MD, FAAD
Professor and Chair, Department of Dermatology
Wake Forest University School of Medicine

Laura Ferris, MD, FAAD
Professor and Chair, Department of Dermatology
University of North Carolina School of Medicine

Suephy Chen, MD, FAAD
Professor and Chair, Department of Dermatology
Duke University School of Medicine

We read with interest the April 2025 DermWorld editorial published by Dr. Warren Heymann and expert viewpoints by Dr. Jane Grant-Kels and Dr. Jeffrey Miller [see above] discussing the body of literature on full body skin exams (FBSE). As seen in these dermatologists’ viewpoints, there remains controversy in the true benefit for population-based FBSE. As academic department chairs in a relatively rural state, and leaders within the academic dermatology community, we wanted to add our perspective to this issue.

Access to dermatology remains challenging and inequitable based on several variables including patient geography, and insurance type and status. Even in areas where there is a relatively high density of board-certified dermatologists, patients can wait months to be seen. This remains true across different practice settings including community and academic dermatology practices.

However, in academic dermatology settings, there are additional layers of complexity that impact patient access. Most academic departments have faculty who see general medical dermatology patients but are also sub-specialized and are responsible for diagnosing and managing some of the most complex dermatologic conditions. Academic institutions often serve as a referral center for challenging patients including those who require multi-disciplinary care coordination across different departments and specialties. Academic institutions also function as safety-net facilities that serve underinsured and uninsured patients who face limited access to dermatologic care even in regions with a relatively high density of board-certified dermatologists. Caring for higher acuity patients provides much-needed access to our sickest patients and supports our academic missions to educate the next generation of dermatologists and to participate in the research that advances care. Dermatology training programs need their residents to be exposed to the full spectrum of dermatologic disease to ensure comprehensive training in their field. Clinical trials run at academic dermatology sites can serve as a key therapeutic option for patients with dermatologic conditions where there are no or few approved therapies.

Demand for FBSE by the general population has increased in the United States, as called out by Dr. Heymann. This may be due to a combination of factors, including referral by primary care providers and social media and other campaigns to raise awareness of skin cancer among the general public without sufficient guidance on higher vs. lower risk of skin cancer incidence and impact on mortality. As with any preventative screening exam, data are needed to examine the risks and benefits of providing the exam. However, one needs to consider the risks and benefits not only to the individual patient, but also to our society at large. Poor triage or prioritization of patients receiving FSBE can inhibit access to dermatologic care by patients who have urgent dermatologic needs. In an ideal world, patients who are at higher risk of mortality from melanoma or aggressive non-melanoma skin cancers would be the patients targeted for screening by dermatologists, and patients who are low risk for skin cancer would be cared for by their primary care physicians. Improved triage and risk stratification of the general population would allow academic dermatologists to optimize their specialized skill set and better fulfill the academic tripartite mission.

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References

1. Nowakowska MK, Li Y, Mohr C, Smith B, Ferris LK, Wehner MR. Prevalence of Total Body Skin Examinations among Dermatology Encounters in Medicare Data: A Retrospective Cohort Study. J Invest Dermatol. 2024 Apr;144(4):905-908.e16. doi: 10.1016/j.jid.2023.09.003. Epub 2023 Sep 25. PMID: 37757914.

2. Jin J. Screening and Prevention of Skin Cancer. JAMA. 2023 Apr 18;329(15):1324. doi: 10.1001/jama.2023.4045. PMID: 37071093.

3. Henrikson NB, Ivlev I, Blasi PR, Nguyen MB, Senger CA, Perdue LA, Lin JS. Skin Cancer Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2023 Apr 18;329(15):1296-1307. doi: 10.1001/jama.2023.3262. PMID: 37071090.

4. Rojas KD, Perez ME, Marchetti MA, Nichols AJ, Penedo FJ, Jaimes N. Skin cancer: Primary, secondary, and tertiary prevention. Part II. J Am Acad Dermatol. 2022 Aug;87(2):271-288. doi: 10.1016/j.jaad.2022.01.053. Epub 2022 Feb 14. PMID: 35176398.

5. Mufti A, Maliyar K, Sachdeva M, Cyr J, Doiron P, Dahlke E. Full Body Skin Examination Practices Among Canadian Dermatologists: Results of a Nationwide Survey. J Cutan Med Surg. 2021 Mar-Apr;25(2):212-215. doi: 10.1177/1203475420974648. Epub 2020 Nov 26. PMID: 33242985.

6. Helm MF, Hallock KK, Bisbee E, Miller JJ. Optimizing the total-body skin exam: An observational cohort study. J Am Acad Dermatol. 2019 Nov;81(5):1115-1119. doi: 10.1016/j.jaad.2019.02.028. Epub 2019 Feb 15. PMID: 30776397.

7. Pham JP, Allen N, Star P, Cust AE, Stewart C, Guitera P, Marghoob AA, Smith A. Full-body skin examination in screening for cutaneous malignancy: a focus on concealed sites and the practices of Australian dermatologists. Int J Dermatol. 2024 Apr;63(4):467-473. doi: 10.1111/ijd.16942. Epub 2023 Nov 30. PMID: 38036942.

8. Grandhi R, Grant-Kels JM. Naked and vulnerable: The ethics of chaperoning full-body skin examinations. J Am Acad Dermatol. 2017 Jun;76(6):1221-1223. doi: 10.1016/j.jaad.2016.12.008. PMID: 28522051.

9. Lee JB. Epidemic of melanoma or epidemic of scrutiny? Dermatology World Insights and Inquiries May 19, 2021; vol 3 no 20. https://staging.aad.org/dw/dw-insights-and-inquiries/archive/2021/epidemic-of-melanoma-or-epidemic-of-scrutiny.

10. Weatherhead SC, Lawrence CM. Melanoma screening clinics: are we detecting more melanomas or reassuring the worried well? Br J Dermatol. 2006 Mar;154(3):539-41. doi: 10.1111/j.1365-2133.2005.07108.x. PMID: 16445788.

11. Muzumdar S, Lin G, Kerr P, Grant-Kels JM. Evidence concerning the accusation that melanoma is overdiagnosed. J Am Acad Dermatol 2021;85:841-846.

12. Grant-Kels J. A commentary on: 2022 Top Story in Dermatology: Is Melanoma Overdiagnosed?. PracticeUpdate website. Available at: https://www.practiceupdate.com/content/2022-top-story-in-dermatology-is-melanoma-overdiagnosed/143591/65/4/3 (Last accessed April 17, 2024).

13. Kulkarni RP, Yu WY, Leachman SA. To Improve Melanoma Outcomes, Focus on Risk Stratification, Not Overdiagnosis. JAMA Dermatol 2022;158:485-487.

14. https://www.nytimes.com/2022/10/19/health/doctors-patients-disabilities.html (Last accessed April 17, 2024).

15. Lagu T, Haywood C, Reimold K, et al. ‘I Am Not The Doctor For You’: Physicians’ Attitudes About Caring For People With Disabilities. Health Affairs 2022;41:1387-1395.

16. Zhou AE, Adalsteinsson JA, Grant-Kels JM. Dermatologic care for patients with mobility-related disabilities. J Am Acad Dermatol 2022;87:E181-182.

17. Meadows LA, Hempstead RW, Grant-Kels JM. Ethical Issues of a Patient Refusing a Full Body Skin Exam. J Am Acad Dermatol – in press. 2023 Sep 30:S0190-9622(23)02885-2. doi: 10.1016/j.jaad.2023.09.063.

18. Hill RC, Grant-Kels JM, Lipner SR. Ethical Considerations For Dermatologists In Managing a Patient Who Declines a Chaperone. J Am Acad Dermatol – in press. DOI:10.1016/j.jaad.2024.02.032

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