Real-time teledermatology clinics in a tertiary public hospital: A clinical audit.

BACKGROUND: Our metropolitan hospital provides a real-time videoconference teledermatology clinic to enable patients in rural and remote Queensland to access a specialist for dermatology care. METHODS: Retrospective clinical audit of all patient referrals to the videoconference teledermatology clinic for a two-year period. RESULTS: A total of 483 consultations for 178 patients were conducted by the teledermatology clinic. Most patients were from remote and very remote regions of Queensland with a mean distance from our metropolitan hospital to the patient's town of residence of 1295 km. The most common reason for referral, as per the referral form, was rash (32%), followed by acne (12%) and dermatitis (11%). Most (78%) referrals came from general practitioners. Around 8% of patients seen in the teledermatology clinic were converted to in-person review; 81% of patients were managed via teledermatology, and 10% of patients did not attend the scheduled teleconsultation. CONCLUSION: The outpatient teledermatology clinic run through the Telehealth Centre of a metropolitan hospital is an effective way of delivering a general dermatology consultation service to rural and remote patients in a timely manner.

True blue football fan: tattoo reaction confined to blue pigment.

A tattoo reaction which appeared solely on the blue pigment of a 6-month old red and blue football club tattoo of an ardent fan was investigated. The patient was otherwise asymptomatic and no other abnormality was detected on full physical examination. Histology revealed a florid sarcoidal granuloma reaction to blue pigment. Preliminary investigations for systemic sarcoidosis did not reveal any abnormality. The tattoo reaction flattened clinically with the institution of a short course of topical mometasone furoate 0.1% ointment and as the subject remained asymptomatic, close surveillance for the development of systemic sarcoidosis is to continue. The possibility of delayed type hypersensitivity is discussed.

Generalized pustular psoriasis of pregnancy treated with narrowband UVB and topical steroids.

A 19-year-old primigravida with a long history of plaque psoriasis presented during the second trimester with exacerbation of the disease. Examination revealed widespread psoriatic plaques with peripheral pustules. She was diagnosed with generalized pustular psoriasis of pregnancy. Histology of lesional skin was consistent with pustular psoriasis. Topical corticosteroids under occlusion resulted in only partial improvement. Hence, narrowband ultraviolet B phototherapy was added at 27 weeks gestation, which resulted in clinical and symptomatic improvement. This is the first case report of generalized pustular psoriasis of pregnancy treated successfully with narrowband ultraviolet B phototherapy.

Periodic painful purpura: fact or factitious?

A 60-year-old woman with multiple psychosocial issues presented with a history of spontaneous painful bruising on her left upper arm. Extensive investigations did not reveal any abnormality apart from an elevated activated partial thromboplastin time as a result of factor XII deficiency. An autoerythrocyte sensitization test reproduced the tender bruises on her back. Our patient reported relief of pain with promethazine injections. She was subsequently referred to the psychiatric team for ongoing assessment and management. Having an awareness of this rare condition will assist in the prevention of unnecessary investigation of such cases and will allow the early referral of patients for appropriate psychological counselling.

Use of 5% imiquimod cream in the treatment of facial basal cell carcinoma: a 3-year retrospective follow-up study.

There has been considerable research into the safety and efficacy of topical 5% imiquimod cream for the treatment of skin cancers in recent years, in particular superficial and nodular basal cell carcinomas. However, there are limited long-term follow-up studies. This retrospective study aims to determine the efficacy of 5% imiquimod cream in the treatment of facial basal cell carcinomas over 3 years. Medical records of 12 patients treated with 5% imiquimod cream at a private dermatology practice during 2001 and 2002 were retrospectively reviewed. Target tumours included superficial and nodular basal cell carcinomas, giving a total lesion number of 19. Patients were commenced on a once daily treatment regimen for up to 9 weeks, and given rest periods as required according to the severity of application site reactions. We found that 5% imiquimod cream is an effective treatment option for superficial and nodular basal cell carcinomas, giving a clearance rate of 89.5% at an average of 39 months of follow up.

Seborrhoeic keratosis and malignancy: collision tumour or malignant transformation?

A retrospective study of 813 histological specimens reported as seborrhoeic keratoses included 43 (5.3%) associated with non-melanoma skin cancer. Intraepidermal carcinoma (squamous cell carcinoma in situ) was the most common of these (36). There were five basal cell carcinomas (one with intraepidermal carcinoma also) and two invasive squamous cell carcinomas. No melanomas were reported. Twenty-seven of the intraepidermal carcinomas appeared to arise within the seborrhoeic keratosis as did one of the invasive squamous cell carcinomas. Of these 28 lesions, the head was the most common site. Fourteen were clinically diagnosed as a non-melanoma skin cancer with only nine clinically felt to be a seborrhoeic keratosis. These lesions may represent malignant transformation within the seborrhoeic keratosis. Twelve specimens reported adjacent dual pathologies, with the trunk and limbs the most common sites. Seven were diagnosed clinically as a skin malignancy, whereas three were thought to be solar keratoses. Clinically, the remaining two were seborrhoeic keratoses. The origin of the malignancy in these cases is less obvious and may represent collision tumours. Three curette specimens could not be assessed for architecture.

Toxic epidermal necrolysis secondary to angioimmunoblastic T-cell lymphoma.

A 67-year-old man presented with a history of lymphadenopathy, fevers and separate skin eruptions of erythrodermic spongiotic dermatitis initially and subsequent toxic epidermal necrolysis. Initial lymph node biopsies showed non-specific granulomatous changes, and skin biopsies and bone marrow aspirate were not diagnostic. His toxic epidermal necrolysis responded well to 3 days of intravenous immunoglobulin. The patient was discharged from hospital and reviewed regularly as an outpatient. Due to persisting lymphadenopathy, further lymph node biopsy led to the diagnosis of angioimmunoblastic T-cell lymphoma, a rare form of peripheral T-cell lymphoma with a poor prognosis. At the time of diagnosis his condition deteriorated rapidly and he died soon after.

Use of biosynthetic dressings in paraneoplastic pemphigus.

A 77-year-old woman with paraneoplastic pemphigus and non-Hodgkin's lymphoma was treated with supportive therapy and oral prednisone. Biobrane, a biosynthetic dressing, was later applied to the extensive areas of erosion to assist in pain management and to provide a temporary barrier function. She reported an improvement in the pain associated with the areas of erosion. The use of biosynthetic dressings in blistering disorders has not been previously reported. Standard dressings such as silver sulfadiazine are messy and can cause discomfort with frequent changing. We feel that this is an area that warrants further evaluation as it may contribute to the overall treatment and comfort cares of these patients.