Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease.

BACKGROUND: Patient outcomes are improved when dermatologists provide inpatient consultations. Inpatient access to dermatologists is limited, illustrating an opportunity to use teledermatology. Little is known about the ability of dermatologists to accurately diagnose disease and manage inpatients with teledermatology, particularly when using nondermatologist-generated clinical data. METHODS: This prospective study assessed the ability of teledermatology to diagnose disease and manage 41 dermatology consultations from a large urban tertiary care center, using internal medicine referral documentation and photographs. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the κ statistic. RESULTS: There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median κ = 0.83), substantial agreement in laboratory evaluation decisions (median κ = 0.67), almost perfect agreement in imaging decisions (median κ = 1.0), and moderate agreement in biopsy decisions (median κ = 0.43). There was almost perfect agreement in treatment (median κ = 1.0), but no agreement in follow-up planning (median κ = 0.0). There was no association between raw photograph quality and the primary plus differential diagnosis or primary diagnosis alone. LIMITATIONS: Selection bias and single-center nature. CONCLUSIONS: Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.

Clinical Diagnostic Accuracy of Onychomycosis: A Multispecialty Comparison Study.

Although onychomycosis can be diagnosed clinically, many guidelines still recommend pathologic confirmation of the diagnosis prior to initiation of systemic treatment. We retrospectively reviewed results from 541 toenail clippings (160 by dermatologists, 198 by podiatrists, and 183 by other provider types) sent to the Brigham and Women's Department of Dermatopathology between January 2000 and December 2013 for confirmatory periodic acid-Schiff (PAS) testing of clinically diagnosed onychomycosis. Of these, 93 (58.1%), 125 (63.1%), and 71 (38.8%) were sent for confirmation of onychomycosis (as opposed to diagnosis of onychodystrophy) by dermatologists, podiatrists, and other provider types, respectively. Confirmatory PAS stains were positive in 70 (75.3%), 101 (80.8%), and 47 (66.2%) of samples ordered by dermatologists, podiatrists, and other providers, respectively. Our study demonstrates that clinical diagnosis of onychomycosis in the appropriate clinical setting is accurate across specialties. Further prospective investigation on the accuracy of clinical diagnosis of onychomycosis may be beneficial.

Cost-effectiveness of Confirmatory Testing Before Treatment of Onychomycosis.

IMPORTANCE: Onychomycosis is the most common disease of the nail in adults. International guidelines urge health care professionals to perform confirmatory diagnostic testing before initiating systemic therapy. This approach was determined to be cost-effective in studies from the late 1990s but has not been evaluated more recently. The effect of testing on the costs of efinaconazole, 10%, topical solution treatment is unknown. OBJECTIVE: To evaluate the cost and potential harm associated with 3 approaches to onychomycosis evaluation before treatment with oral terbinafine or efinaconazole, 10%. DESIGN, SETTING, AND PARTICIPANTS: A decision analysis that compared the costs of 3 onychomycosis management algorithms based on recently published data of test statistics, disease prevalence, and relevant costs: (1) empirical therapy without confirmatory testing, (2) pretreatment confirmatory testing with potassium hydroxide (KOH) stain followed by periodic acid-Schiff (PAS) evaluation if KOH testing is negative, and (3) pretreatment testing with PAS. There was no direct patient evaluation. Selection of included studies was based on outcome variables and the quality of study design. The study was conducted from April 1, 2014, to September 1, 2015. MAIN OUTCOMES AND MEASURES: Primary outcomes included direct cost of onychomycosis testing and therapy and cost to avoid harm when treating patients with oral terbinafine. RESULTS: At a disease prevalence of 75%, per-patient cost savings of empirical terbinafine therapy without confirmatory testing was $47 compared with the KOH screening model and $135 compared with PAS testing. The cost of testing necessary to prevent a single case of clinically relevant liver toxic effects related to terbinafine at a prevalence of 75% was between $18.2 million and $43.7 million for KOH screening and between $37.6 million and $90.2 million for PAS testing. At a prevalence of 75%, KOH screening and PAS testing before treatment with efinaconazole, 10%, saved $272 and $406 per patient per nail, respectively. CONCLUSIONS AND RELEVANCE: These results show that empirical treatment with terbinafine for patients with suspected onychomycosis is more cost-effective than confirmatory testing across all prevalence of disease, with minimal effect on patient safety. In contrast, confirmatory testing before treatment with efinaconazole, 10%, is associated with reduced costs. Blanket recommendations for confirmatory testing before systemic therapy should be reconsidered and replaced with recommendations tailored to specific therapies.

Gigapixel photography for skin cancer surveillance: a novel alternative to total-body photography.

There is substantial evidence supporting the use of cutaneous imaging in combination with standard total-body skin examinations for early detection and treatment of melanoma. In the last 2 decades, total-body photography (TBP) has been widely used in combination with standard total-body skin examinations for active skin cancer surveillance with proven clinical utility; however, the groundbreaking image detail provided by gigapixel photography (GP) could improve dermatologists' ability to monitor suspicious lesions and therefore could serve a critical role in supplementing traditional total-body skin examinations for skin cancer surveillance. Although it has been successfully implemented in other fields, future studies are required to determine the effectiveness of GP in dermatology.

Utility of adjunctive macrolide therapy in treatment of children with asthma: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study was to investigate macrolides as an adjunct to an asthma controller regimen in children with asthma. METHODS: Prospective clinical trials of macrolide therapy in children with asthma using outcome measures of change in forced expiratory volume in one second (FEV(1)) and/or oral corticosteroid requirement were searched for in PubMed up to December 2009. The reference lists of studies were also included in the analysis, as well as those listed in published meta-analyses. RESULTS: The literature search yielded 116 studies, six of which were included in this meta-analysis. The change in FEV(1) from baseline with adjunctive use of macrolide therapy in all children was not significant (0.25% predicted; 95% confidence interval [CI] -0.37, 0.86 predicted, P = 0.43); however, the change in FEV(1) among children receiving daily oral corticosteroids was significant (3.89% predicted; 95% CI -0.01, 7.79, P = 0.05). Addition of macrolide therapy to the treatment of children with oral corticosteroid-dependent asthma resulted in a statistically significant decrease in daily corticosteroid dosage (-3.45 mg/day; 95% CI -5.79, -1.09 mg/day, P = 0.004). This reduction in daily corticosteroid dosage was directly proportional to the duration of macrolide therapy (-0.17 mg methylprednisolone per week of macrolide therapy; 95% CI -0.33, -0.021, P = 0.025). CONCLUSION: Addition of macrolides to the treatment regimen of children with oral corticosteroid-dependent asthma improves FEV(1) and decreases the daily dosage of corticosteroids required for control in these children. The degree of dose reduction is directly related to the duration of macrolide therapy. Additional large, randomized, placebo-controlled trials of adjunctive macrolide use in children with oral corticosteroid-dependent asthma are required to verify this observation.