Outcomes of Risk-Stratified Face-to-Face and Teledermoscopy Pathways for Skin Lesion Referrals: A Retrospective Service Evaluation

Background: Skin cancer referrals to secondary care continue to rise, and teledermoscopy has been incorporated into NHS urgent suspected cancer (USC) pathways to support triage. Direct comparisons of outcomes across deliberately risk-stratified face-to-face (FTF) and teledermoscopy referral pathways, within the same service, time period, and assessing consultant, remain limited. Methods: We retrospectively compared outcomes across two risk-stratified referral pathways within the same dermatology service over a six-month period (July-December 2025): 201 patients with 207 index lesions assessed via FTF clinics, and 378 patients with 415 lesions assessed via teledermoscopy. All patients were reviewed by the same dermoscopy-trained consultant. Referral urgency, initial clinical impression, clinic outcome, and histology were recorded. The two pre-specified headline outcomes - discharge rate and malignancy yield - are reported as absolute differences between pathways with 95% confidence intervals; all other between-cohort comparisons are descriptive/exploratory and were not adjusted for multiplicity. Results: FTF referrals were predominantly USC referrals (175/201, 87.0%), with a malignancy yield of 57/207 index lesions (27.5%). The discharge rate was 72/201 patients (35.8%), and 116/201 patients (57.7%) required minor operative procedures. Teledermoscopy referrals were more evenly distributed across urgency categories, with 193/378 patients (51.1%) referred as USC. Malignancy yield, excluding in situ disease, was 60/415 lesions (14.5%), 13.1 percentage points lower than FTF (95% CI: 6.1-20.0); including in situ disease, yield was 63/415 (15.2%), a difference of 13.8 percentage points (95% CI: 6.7-20.9) The discharge rate at initial assessment was 206/378 patients (54.5%), 18.7 percentage points higher than FTF (95% CI: 10.4-27.0). Basal cell carcinoma was the leading confirmed malignancy in both pathways. Incidental lesions were identified in 25/201 FTF assessments (12.4%), of which 24/25 (96.0%) were skin cancers, predominantly basal cell carcinomas. Conclusions: Within the same service and assessing consultant, teledermoscopy was associated with a substantially higher discharge rate while still detecting skin cancers across referral categories. Much of this difference likely reflects image-based triage allocating lower-suspicion referrals to teledermoscopy, rather than a difference in diagnostic performance between the two modalities; these findings should be interpreted as a descriptive evaluation of pathway throughput rather than a head-to-head comparison of diagnostic accuracy. These findings support the continued, risk-stratified integration of teledermoscopy into NHS skin cancer referral pathways.