Tele-expertise for diagnosis of skin lesions is cost-effective in a prison setting: A retrospective cohort study of 450 patients.

CONTEXT: The prevalence of skin diseases among prisoners is higher than in the general population. Diagnosing and treating these lesions require a dermatologic advice. A tele-expertise network in dermatology for prisoners including 8 health facilities in prison and 2 hospital dermatological departments was developed to improve access to dermatologists' expertise in correctional facilities. Our objective was to evaluate the effectiveness and costs of tele-expertise in dermatology for prisoners. METHODS: We carried out a retrospective cohort study on data collected by the information system of the tele-expertise network. We used the MAST (Model for ASsessment of Telemedicine) model to perform a multidimensional assessment including the proportion of patients with a completed treatment plan for the skin lesions, the proportion of technical problems, the quality of the pictures, the investment and operating costs and the satisfaction of the professionals. RESULTS: Mean patient age was 34.2 years with 90% men. 511 requests for 450 patients were initiated. The delay from the connection to the tele-expertise software to the validation of the request was inferior to 7 min for 50% of the requests and inferior to 30 min for 85% of the requests. Overall, with tele-expertise, 82% of the patients had a completed treatment plan for the skin lesions, with 2.9% of all patients requiring a later face-to-face appointment or hospitalization, to be compared to a proportion of 35% of patients with a completed treatment plan when tele-expertise was not available. The most frequent lesions were acnea (22%) and atopic dermatitis (18%). The mean cost for one completed treatment plan was €184 by tele-expertise and €315 without tele-expertise. Tele-expertise was well accepted among physicians with all responders (n = 9) willing to continue using it. CONCLUSION: Tele-expertise is a dominant intervention in comparison to a face-to face consultation taking into account the cost of transportation and the proportion of canceled appointments and is acceptable for physicians. TRIAL REGISTRATION: NCT02309905.

Necrotizing cellulitis with multiple abscesses on the leg caused by Serratia marcescens.

Serratia marcescens is an unusual cause of severe skin infection initially described in immunocompromised patients. We report a case of necrotizing cellulitis of the leg caused by S marcescens in a 68-year-old woman with diabetes mellitus and a history of chronic lymphoedema of the leg. We reviewed the literature and found 49 cases of severe skin infections from S marcescens that included 20 cases of necrotizing fasciitis (NF) as well as 29 cases of severe skin infections without NF (non-NF cases). Patients were immunocompromised in 59% to 70% of cases. The mortality rate was high in NF cases (60%) versus non-NF cases (3%). Surgery was required in 95% of NF cases and in 24% of non-NF cases. The other clinical manifestations of S marcescens skin infection reported in the literature included disseminated papular eruptions in patients infected with human immunodeficiency virus with folliculitis on the trunk. Serratia marcescens is naturally resistant to amoxicillin alone and amoxicillin associated with clavulanic acid. Broad-spectrum antibiotics are indicated to treat S marcescens skin infections, and surgery should be promptly considered in cases of severe skin infections if appropriate antibiotic therapy does not lead to rapid improvement.

Emergency department diagnosis and management of skin diseases with real-time teledermatologic expertise.

IMPORTANCE: Skin conditions are a common reason for patients to consult emergency department (ED) physicians. OBJECTIVE: To evaluate real-time teledermatologic expertise with the use of mobile telephones for the diagnosis and management of skin conditions in patients seen in the ED. DESIGN, SETTING, AND PARTICIPANTS: This observational study of adults who consecutively consulted in the ED for a dermatologic condition was conducted under routine conditions in the ED from May 1, 2008, through June 30, 2010. MAIN OUTCOMES AND MEASURES: Diagnosis agreement and management concordance. RESULTS: One hundred eleven patients were enrolled in the study. Eighty-three patients (74.8%) were evaluated using videoconferencing. Dermatologic remote expertise invalidated, enlarged, or clarified ED physicians' diagnosis and management in 75 of 110 cases (68.2%). Videoconferencing improved the diagnostic performance in 57 of 83 cases (68.7%) (P < 10(-4)). Management concordance was moderate between ED physicians and dermatologists for specialist consultation within 24 hours (κ, 0.49; 95% CI, 0.14-0.84) and immediate hospitalization (κ, 0.49; 95% CI, 0.41-0.57). Patients were significantly more often discharged by dermatologists (46.8% vs 39.1%) (P < 10(-4)). CONCLUSIONS AND RELEVANCE: Compared with standard hardware, new-generation mobile devices reduce the cost of videoconferencing, increase the versatility of teledermatology, and decrease general practitioner investment time.

Identifying the biologic closest to the ideal to treat chronic plaque psoriasis in different clinical scenarios: using a pilot multi-attribute decision model as a decision-support aid.

OBJECTIVE: Multi-attribute decision-making (MADM) models evaluate competing solutions for complex problems to identify the closest fit to the ideal solution. MADM models may assist dermatologists when selecting between biologics for plaque psoriasis. Here, is described the development of a pilot model to identify the preferred biologic from the dermatologist's perspective. RESEARCH DESIGN AND METHODS: A group of European dermatologists were surveyed to identify treatment attributes they consider when prescribing a biologic. The relative importance of each was determined by allocation of 100 importance points in the context of seven case vignettes, reflecting the breadth of disease encountered in dermatological practice. Biologic performance was rated anonymously on a scale of 1-10, scores entered into a MADM matrix, and TOPSIS (Technique for Ordered Preference by Similarity to the Ideal Solution) analysis applied to identify the biologic closest to the hypothetical ideal. RESULTS: Long-term efficacy and safety were the most important attributes considered by dermatologists when selecting a biologic. For one case vignette (chronic stable psoriasis), TOPSIS scores showed that etanercept was closest to the ideal for 63% of respondents, with adalimumab closest to the ideal for 32% of respondents. Differences among the biologics were highly significant (p < 0.0001). For severe unstable psoriasis, infliximab and adalimumab were preferred. LIMITATION: This study was conducted with a group of dermatologists attending a Wyeth-sponsored advisory board meeting. CONCLUSIONS: Based on responses from this expert group, etanercept was the preferred choice for stable chronic plaque psoriasis for the majority, with infliximab preferred for more severe disease. However, there are several limitations to this pilot model, most notably the non-random selection of the expert group. Further development of the model encompassing a random survey of dermatologists and inclusion of other treatment alternatives and the latest clinical data, will add to the clinical utility of the tool.

Efficacy of infliximab for severe recalcitrant psoriasis after 6 weeks of treatment.

Infliximab treatment has been shown to be effective for moderate-to-severe psoriasis in several large clinical trials. Nonetheless, experience with this new treatment is still needed to evaluate its efficacy and tolerance in everyday practice. In this follow-up study, we report our experience with infliximab for recalcitrant psoriasis. Nineteen patients with recalcitrant psoriasis were treated between July 2004 and December 2006 with 5 mg/kg infliximab i.v. at weeks 0, 2 and 6 followed by maintenance every 8 weeks. In three patients resistant to treatment, methotrexate was added at a 15-25 mg dose weekly after the sixth week of infliximab therapy. Pretreatment evaluations included chest X-ray, tuberculin test (5 units), full blood count, kidney and liver function tests, antinuclear antibodies and patient weight. Response to treatment, using the Psoriasis Area and Severity Index (PASI) score, and adverse effects were prospectively assessed at weeks 0, 6 and 22. At week 6, after only two infusions, 78.9% (15/19) of patients showed at least 75% improvement in baseline PASI (PASI 75). At week 22, 73.6% (14/19) patients had reached PASI 75. Three patients had a relapse. Four developed adverse effects that required suspension of infliximab therapy. No tuberculosis or lymphoproliferative disease was observed. Four patients (21%) showed apparition of positive antinuclear antibody during the course of treatment and 57.8% (11/19) of patients showed an increase in weight at week 22. Our experience shows that infliximab is a very rapidly effective treatment of severe, treatment-resistant psoriasis as soon as the sixth week of treatment.