Successful melanoma triage by a virtual lesion clinic (teledermatoscopy).

BACKGROUND: A Virtual Lesion Clinic (VLC) using teledermatoscopy was established to improve efficiency of the melanoma referral pathway. OBJECTIVES: To assess diagnostic accuracy and to compare wait-times and costs of VLC and conventional clinics. METHODS: Patients with suspected melanoma referred from primary care into a publicly funded health system attended local skin imaging centres, rather than hospital outpatient clinics. A teledermatologist assessed each lesion choosing specialist assessment/excision, General Practitioner (GP) follow-up, to re-image in 3 months, or self-monitoring/no concern. RESULTS: 613 skin lesions in 310 patients were evaluated over 12 months. Median time between receipt of referral and attendance at the VLC was 9 days compared to 26.5 days for standard outpatient assessment. Sixty-six percent (404/613) of lesions were considered benign, and 12% (73/613) were suspicious for melanoma. Of 129 lesions excised, 98 were skin cancers including 48 histologically confirmed melanomas with one spitzoid tumour of unknown malignant potential (STUMP), i.e. one melanoma per 1.59 suspected lesions biopsied and one melanoma in every 12.8 referred to the service. There were 49 non-melanoma skin cancers (NMSC). Teledermatoscopic diagnosis of melanomas was found to have a positive predictive value (PPV) of 63%. Compared to the conventional clinic, cost reductions from running the VLC for 1 year were in excess of NZ$364,000 (or NZ$1174/patient seen). CONCLUSIONS: The VLC offered an efficient, accurate and cost effective way of processing suspected melanoma referrals to the public health system.

Practising dermatology via telemedicine.

AIM: An interactive telemedicine service has been established between Taumarunui Hospital and the Department of Dermatology at Waikato Hospital. The first one hundred dermatological consultations were reviewed to see if the consultations were satisfactory for medical staff and patients. METHODS: A proprietary video conferencing system communicating via the Integrated Systems Digital Network was used to conduct dermatological consultations. Data were collected regarding waiting time, diagnosis and follow-up arrangements. Each patient was asked to complete a questionnaire after the consultation. RESULTS: Of these consultations, 83 were newly referred patients and the rest were follow-ups. The median waiting time for a new patient was 63 days. A variety of skin lesions (in 40 patients), inflammatory eruptions (31) and infections (13) were diagnosed and managed. Sixteen patients had to be seen at the base hospital for surgical treatment (7), face-to-face diagnosis (3), patch testing (3), a second opinion (2), or for personal reasons (1). The others were followed up locally. Savings in time and cost to patients were noted particularly. CONCLUSION: Only about 20% of consultations with new patients resulted in a further face-to-face appointment. The majority of patients found the telelink acceptable. The data supported the continuation and possible expansion of the dermatology telemedicine service. However, improved image quality is desirable.

Diagnostic accuracy of teledermatology: results of a preliminary study in New Zealand.

AIM: To determine the accuracy of a video conferencing system (telemedicine) in diagnosis of dermatological disorders. METHODS: New patients referred to a dermatology clinic were initially examined by telemedicine and then by a standard face to face consultation. The diagnoses made by each type of consultation were compared and accuracy of telemedicine determined. RESULTS: One hundred and four patients with 135 dermatological conditions were analysed. Seventy five percent of conditions were correctly diagnosed by telemedicine. In a further 7% a differential diagnosis was made, which included the final diagnosis made face to face. In 12%, the diagnosis was incorrect using the telemedicine system, and in 3% no diagnosis was made. Four per cent of diagnoses were only made when the patient was seen face to face. CONCLUSION: This preliminary study suggests that video conferencing equipment can be used with a reasonable degree of accuracy for the diagnosis of dermatological disease.

Skin clips are contraindicated when there is nickel allergy.

Four patients are described who developed generalized dermatitis following surgical wound closure with disposable skin clips. In 3 of them a vesicular palmar eczema was a prominent feature. They were found to have contact allergy to nickel, a component of the clips. If skin clips are to be used to close a surgical wound, it should be established that the patient is not allergic to nickel.

Patient cost-benefits of realtime teledermatology--a comparison of data from Northern Ireland and New Zealand.

As part of a randomized controlled trial of the costs and benefits of realtime teledermatology in comparison with conventional face-to-face appointments, patients were asked to complete a questionnaire at the end of their consultation. One hundred and nine patients took part in an initial teledermatology consultation and 94 in a face-to-face consultation. The proportion of patients followed up by the dermatologist was almost the same after teledermatology (24%) as after a hospital appointment (26%) and for similar reasons. Two hundred and three questionnaires were completed after the first visit and a further 20 after subsequent visits. Patients seen by teledermatology at their own health centre travelled an average of 12 km, whereas those who attended a conventional clinic travelled an average of 271 km. The telemedicine group spent an average of 51 min attending the appointment compared with 4.3 h for those seen at the hospital. The results of the present study, as in a similar study conducted in Northern Ireland, show that the economic benefits of teledermatology favour the patient rather than the health-care system.

The Acne Disability Index: usefulness confirmed.

One hundred and four patients with acne completed a questionnaire derived from the Cardiff Acne Disability Index Questionnaire. In addition, 59% of patients returned an identical follow-up questionnaire 6 months later. Significant disability from acne was identified in many patients, with the median initial Acne Disability Index (ADI) being 6 (maximum possible 15), improving to 3 after treatment. Scores correlated poorly with the clinical severity of acne. The questionnaire proved useful for identifying patients with poor self-image who might benefit from more potent treatment for their acne, and to evaluate the effect of treatment.

Teledermatology in New Zealand.

BACKGROUND: Teledermatology is the delivery of specialist dermatological services at a distance. It has become possible because of technological advances in digital imaging and telecommunications. Consultations may be "interactive" using video-conferencing equipment or "store-and-forward" using prerecorded text and images. The best method to deliver teledermatology services is unknown. OBJECTIVE: Studies were designed to determine (a) if it was possible to diagnose and manage skin diseases using video-conferencing equipment, (b) if teledermatology was acceptable to patients and medical practitioners, and (c) whether it offered any economic advantages. We have also compared interactive and store-and-forward techniques. METHOD: The trials were conducted in collaboration with the Institute of Telemedicine & Telecare, Queen's University, Belfast, as part of the UK Teledermatology Trials. RESULTS: The trials have involved more than 300 teledermatology consultations. Having established that a diagnosis can be made in more than two-thirds of the cases, the majority of video consultations have resulted in satisfactory management, with only small numbers of patients requiring face-to-face review. Teledermatology is generally popular with patients and can save them considerable time and money. Routine clinics continue in three centers. We have found that effective store-and-forward teledermatology requires very good images and comprehensive historical referral data.

Rapid repigmentation after depigmentation therapy: vitiligo treated with monobenzyl ether of hydroquinone.

Repigmentation occurred within a few weeks of discontinuing successful depigmentation therapy with monobenzyl ether of hydroquinone, in a patient with extensive vitiligo. Patients undertaking depigmentation therapy should be warned that this may occur. The mechanism is unknown.

A review of ultraviolet treatment for psoriasis at Waikato Hospital.

Details of 79 courses of UVB and 40 courses of PUVA for patients with chronic plaque psoriasis at Waikato Hospital were prospectively collected when a new Phototherapy Unit opened. Efficacy was assessed by clearance rates (73% for UVB, 87.5% for PUVA). There was significant improvement in Psoriasis Disability Index, which was derived from a questionnaire assessing functional disability and completed by the patients before and after treatment. It took a median number of 24 treatments for psoriasis in the patients receiving UVB to clear, and for the PUVA patients the median was 19 treatments. The efficacy could not be correlated with skin type. Fifty per cent of UVB patients and 25% of PUVA patients received symptomatic burns, all localized and minor in nature. LIfetime PUVA dose was calculated, 90% of patients having received less than 400 J/cm2.

The onset of ultraviolet erythema.

The onset of erythema induced by UVB and by UVC radiation was monitored in two subjects using a reflectance instrument. It was shown that vasodilation occurred some time before erythema became visible, even with small exposure doses of UVB or UVC, after which visible erythema was not apparent for several hours. In one subject, vasodilation was detected very shortly after irradiation and may have even begun during irradiation. In the other subject vasodilation was detected later at most exposure doses, but still some time before erythema became visible. We conclude that the so-called 'latent period' between irradiation and appearance of erythema is an artificial concept arising from the insensitivity of the eye.

Cutaneous vasculitis from maprotiline.

An 83 year old woman with depression, while receiving maprotiline, developed a vasculitic skin eruption which resolved on discontinuing the drug. Vasculitis has not previously been reported with this drug.

Quantitative studies on UVA-induced erythema in human skin.

The erythemal response of normal human skin to UVA and UVB radiation was measured objectively using a reflectance instrument in seven subjects, and a laser Doppler velocimeter in two subjects. UVA radiation was produced using a newly-developed high-intensity UVA lamp. The slope of the log dose-erythemal response curve for UVA at 24 h after irradiation was found not to differ significantly from that for UVB. The time course of UVA erythema was biphasic; erythema was present immediately after irradiation, fell to a minimum at about 4 h and then rose to a broad plateau between 6 and 24 h. The intensity of the early phase was dose-rate dependent, whereas that in the later phase depended on dose only.