Telemedicine Chapter 7: Telemedicine and Dermatology

This chapter is part of Literature reviews carried out for the Heath Service Executive National Telehealth Steering Group April – July 2020

Systematic Reviews

Andrees et al (2020) [Systematic Review] Live interactive
teledermatology compared to in-person care -a systematic review1

Teledermatology is a rapidly developing field of dermatological care, giving the opportunity to deliver more efficient healthcare to patients in remote areas. Live interactive (LI) teledermatology uses videoconferencing and, hence, allows for direct communication. A current overview on effectiveness, costs, feasibility and accuracy of LI applications compared to standard care is missing. The present systematic review provides this overview on LI teledermatology. Two databases were searched until April 2019, followed by title, abstract and full-text screening. Additionally, reference lists of the detected eligible articles were screened for further eligible studies. Studies comparing LI applications with standard care were included. Data on study design, sample size, country, objectives, main findings and characteristics of LI applications were extracted. Results on time effectiveness, costs, accuracy and feasibility of LI applications were synthesized. Additionally, the quality of included studies was assessed. Twenty-three publications were included in the final analysis: seventeen case-control studies and six randomized controlled trials. Included studies were published between 1997 and 2017. Study quality differed across studies. The studies were carried out in eight different countries. Eleven studies focused on patient consultation, three on patient organization and nine on combined applications of the aforementioned. Nine studies investigated applications facilitating patient-provider interaction. Fourteen studies evaluated applications combining patient-provider and provider-provider interaction, meaning the patient sits next to one provider while using LI applications to interact with another provider. This review reveals that LI applications can be a time effective substitute of or supplement to standard dermatological care. Results demonstrated that LI and standard care are comparable with regard to feasibility and accuracy. No clear tendencies can be reported with regard to costs. However, there is a lack of current comparative studies

Freeman et al (2020) [Systematic Review] Algorithm based smartphone apps to assess risk of skin cancer in adults: systematic review of diagnostic accuracy studies2

Objective: To examine the validity and findings of studies that examine the accuracy of algorithm based smartphone applications (“apps”)to assess risk of skin cancer in suspicious skin lesions. Design: Systematic review of diagnostic accuracy studies. Data sources: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, and online trial registers from database inception to 10 April, 2019. Eligibility criteria for selecting studies: Studies of any design that evaluated algorithm based smartphone apps to assess images of skin lesions suspicious for skin cancer. Reference standards included histological diagnosis or follow-up, and expert recommendation for further investigation or intervention. Two authors independently extracted data and assessed validity using QUADAS-2. Estimates of sensitivity and specificity were reported for each app. Results: Nine studies that evaluated six different identifiable smartphone apps were included. Six verified results by using histology or follow-up (n=725 lesions), and three verified results by using expert recommendations (n=407 lesions). Studies were small and of poor methodological quality, with selective recruitment, high rates of unevaluable images, and differential verification. Lesion selection and image acquisition were performed by clinicians rather than smartphone users. Two CE [Conformit Europenne] marked apps are available for download. No published peer reviewed study was found evaluating the TeleSkin skinScan app. SkinVision was evaluated in three studies (n=267, 66 malignant or premalignant lesions) and achieved a sensitivity of 80% (95% confidence interval 63% to 92%) and a specificity of 78% (67% to 87%)for the detection of malignant or premalignant lesions. Accuracy of the SkinVision app verified against expert recommendations was poor (three studies). Conclusions: Current algorithm based smartphone apps cannot be relied on to detect all cases of melanoma or other skin cancers. Test performance is likely to be poorer than reported here when used in clinically relevant populations and by the intended users of the apps. The current regulatory process for awarding the CE marking for algorithm based apps does not provide adequate protection to the public.

Pala et al (2020) [Systematic Review] Teledermatology: idea, benefits and risks of modern age -a systematic review based on melanoma3

Telemedicine may be described as a modern technology supporting health care at a distance. Dermatology, as a visually-dependent specialty, is particularly suited for this kind of the health care model. This has been proven in a number of recent studies, which emphasized feasibility and reliability of teledermatology. Many patients in the world still do not have access to appropriate dermatological care, while skin cancers morbidity is on an upward trend. Technological development has enabled clinicians to care for diverse patient populations in need of skin expertise without increasing their overhead costs. Teledermatology has been used for various purposes: health care workers can use this technology to provide clinical services to patients, to monitor patient health, to consult with other health care providers and to provide patients with access to educational resources. It seems that teledermatology might be the answer to numerous issues concerning diagnosing, screening and managing cancers as well as pigmented skin lesions.

Bruce et al (2018) [Systematic Review] The use of teledermoscopy in the accurate identification of cancerous skin lesions in the adult population: A systematic review4

Background: The use of teledermoscopy in the diagnostic management of pre-cancerous and cancerous skin lesions involves digital dermoscopic images transmitted over telecommunication networks via email or web applications. Teledermoscopy may improve the accuracy in clinical diagnoses of melanoma skin cancer if integrated into electronic medical records and made available to rural communities, potentially leading to decreased morbidity and mortality. Objective and Method: The purpose of this paper is to present a systematic review of evidence on the use of teledermoscopy to improve the accuracy of skin lesion identification in adult populations. The PRISMA method guided the development of this systematic review. A total of seven scholarly databases were searched for articles published between the years of 2000 and 2015. All studies were critically appraised using the Rosswurm and Larrabee critique worksheet, placed in a matrix for comparison evaluating internal and external validity and inspected for homogeneity of findings. Results: Sixteen articles met inclusion criteria for this review. A majority of the studies were cross-sectional and non-experimental. Ten of the 16 focused on interobserver concordance and diagnostic agreement between teledermoscopy and another comparator. Instrumentation in conducting the studies showed inconsistency with reported results. Discussion: Higher level evidence is needed to support clinical application of teledermoscopy for accuracy of diagnostic measurement in the treatment of pre-cancerous and cancerous skin lesions in adults. Future research is needed to develop a standardized, reliable and valid measurement tool for implementation in clinical practice.

Choi et a (2018) [Systematic Review]mHealth Approaches in Managing
Skin Cancer: Systematic Review of Evidence-Based Research Using
Integrative Mapping5

Background: mHealth, which encompasses mobile health technologies and interventions, is rapidly evolving in various medical specialties, and its impact is evident in oncology. In particular, mHealth has established itself as a prominent part of dermatology for cancer screening. Intensified research to seek its use and effectiveness in each phase of the skin cancer continuum is needed in this fast-growing field of teledermatology. Objective: The purpose of this review was to describe current trends in research addressing the integration of mHealth and its contributions across the skin cancer continuum. Methods: A systematic review framework was applied to the search using three electronic databases: PubMed, Web of Science, and Embase. We extensively reviewed appropriate studies regarding skin cancer and mobile technology published between 2007 and 2017. Studies of the role and impact of mobile technology in the prevention and management of skin cancer were included. We selected 18 studies adhering to the inclusion and exclusion criteria for analysis. Results: Of the 18 studies, 5 (28%) evaluated prevention interventions, 6 (33%) assessed diagnostic accuracy, and 7 (39%) pertained to feasibility in the context of mHealth approaches for skin cancer care. These studies portray the potential of mobile teledermatology in the prevention and management of skin cancer. However, not all phases of skin cancer involve mHealth, and not all have been addressed by research. Conclusions: This review extends our knowledge not only on the contributions of mHealth technologies, but also on their integration in different phases of skin cancer care. To optimize the effectiveness of mHealth in dermatology, larger numbers of robust, evidence-based studies on teledermatology implementations, distributed evenly across the care continuum, should be conducted so that research can be expanded to systematic reviews.

Chuchu et al (2018) [Systematic Review] Smartphone applications for triaging adults with skin lesions that are suspicious for melanoma6

Background: Melanoma accounts for a small proportion of all skin cancer cases but is responsible for most skin cancer-related deaths. Early detection and treatment can improve survival. Smartphone applications are readily accessible and potentially offer an instant risk assessment of the likelihood of malignancy so that the right people seek further medical attention from a clinician for more detailed assessment of the lesion. There is, however, a risk that melanomas will be missed and treatment delayed if the application reassures the user that their lesion is low risk. Objectives: To assess the diagnostic accuracy of smartphone applications to rule out cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with concerns about suspicious skin lesions. Search methods: We undertook a comprehensive search of the following databases from inception to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. Selection Criteria: Studies of any design evaluating smartphone applications intended for use by individuals in a community setting who have lesions that might be suspicious for melanoma or atypical intraepidermal melanocytic variants versus a reference standard of histological confirmation or clinical follow-up and expert opinion.

Data Collection and Analysis: Two review authors independently extracted all data using a standardised data extraction and quality assessment form based on QUADAS-2. Due to scarcity of data and poor quality of studies, we did not perform a meta-analysis for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for each application under consideration. Main Results: This review reports on two cohorts of lesions published in two studies. Both studies were at high risk of bias from selective participant recruitment and high rates of non-evaluable images. Concerns about applicability of findings were high due to inclusion only of lesions already selected for excision in a dermatology clinic setting, and image acquisition by clinicians rather than by smartphone app users.We report data for five mobile phone applications and 332 suspicious skin lesions with 86 melanomas across the two studies. Across the four artificial intelligencebased applications that classified lesion images as melanomas [one application] or as high risk or problematic lesions [three applications]using a pre-programmed algorithm, sensitivities ranged from 7% (95% CI 2% to 16%)to 73% (95% CI 52% to 88%) and specificities from 37% (95% CI 29% to 46%)to 94% (95% CI 87% to 97%). The single application using store-andforward review of lesion images by a dermatologist had a sensitivity of 98% (95% CI 90% to 100%) and specificity of 30% (95% CI 22% to 40%).The number of test failures lesion images analysed by the applications but classed as unevaluable and excluded by the study authors ranged from 3 to 31 (or 2% to 18% of lesions analysed). The store-and-forward application had one of the highest rates of test failure (15%). At least one melanoma was classed as unevaluable in three of the four application evaluations.

Authors’ Conclusions: Smartphone applications using artificial intelligencebased analysis have not yet demonstrated sufficient promise in terms of accuracy, and they are associated with a high likelihood of missing melanomas. Applications based on store-and-forward images could have a potential role in the timely presentation of people with potentially malignant lesions by facilitating active self-management health practices and early engagement of those with suspicious skin lesions; however, they may incur a significant increase in resource and workload. In respect ofthe paucity of evidence and low methodological quality of existing studies, it is not possible to draw any implications for practice. Nevertheless, this is a rapidly advancing field, and new and better applications with robust reporting of studies could change these conclusions substantially

Chuchu et al (2018) [Systematic Review]Teledermatology for diagnosing skin cancer in adults7

Background: Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC)is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Teledermatology provides a way for generalist clinicians to access the opinion of a specialist dermatologist for skin lesions that they consider to be suspicious without referring the patients through the normal referral pathway. Teledermatology consultations can be ‘store-and-forward’ with electronic digital images of a lesion sent to a dermatologist for review at a later time, or can be live and interactive consultations using videoconferencing to connect the patient, referrer and dermatologist in real time. Objectives: To determine the diagnostic accuracy of teledermatology for the detection of any skin cancer melanoma, BCC or cutaneous squamous cell carcinoma (cSCC) in adults, and to compare its accuracy with that of inperson diagnosis.

Search methods: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, US National Institutes of Health Ongoing Trials Register, NIHR Clinical Research Network Portfolio Database and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. Selection criteria: Studies evaluating skin cancer diagnosis for teledermatology alone, or in comparison with face-to-face diagnosis by a specialist clinician, compared with a reference standard of histological confirmation or clinical follow-up and expert opinion. We also included studies evaluating the referral accuracy of teledermatology compared with a reference standard of face-to-face diagnosis by a specialist clinician. Data collection and analysis: Two review authors independently extracted all data using a standardised data extraction and quality assessment form based on QUADAS-2. We contacted authors of included studies where there were information related to the target condition of any skin cancer missing. Data permitting, we estimated summary sensitivities and specificities using the bivariate hierarchical model. Due to the scarcity of data, we undertook no covariate investigations for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for diagnostic threshold and target condition under consideration.

Main results: The review included 22 studies reporting diagnostic accuracy data for 4057 lesions and 879 malignant cases [16 studies] and referral accuracy data for reported data for 1449 lesions and 270 positive cases as determined by the reference standard face-to-face decision [6 studies]. Methodological quality was variable with poor reporting hindering assessment. The overall risk of bias was high or unclear for participant selection, reference standard, and participant flow and timing in at least half of all studies; the majority were at low risk of bias for the index test. The applicability of study findings were of high or unclear concern for most studies in all domains assessed due to the recruitment of participants from secondary care settings or specialist clinics rather than from primary or community-based settings in which teledermatology is more likely to be used and due to the acquisition of lesion images by dermatologists or in specialist imaging units rather than by primary care clinicians.Seven studies provided data for the primary target condition of any skin cancer: 1588 lesions and 638 malignancies. For the correct diagnosis of lesions as malignant using photographic images, summary sensitivity was 94.9% (95% confidence interval (CI) 90.1% to 97.4%) and summary specificity was 84.3% (95% CI 48.5% to 96.8%). Individual study estimates using dermoscopic images or a combination ofphotographic and dermoscopic images generally suggested similarly high sensitivities with highly variable specificities. Limited comparative data suggested similar diagnostic accuracy between teledermatology assessment and in-person diagnosis by a dermatologist; however, data were too scarce to draw firm conclusions. For the detection of invasive melanoma or atypical intraepidermal melanocytic variants both sensitivities and specificities were more variable. Sensitivities ranged from 59% (95% CI 42% to 74%)to 100% (95% CI 48% to 100%) and specificities from 30% (95% CI 22% to 40%)to 100% (95% CI 93% to 100%), with reported diagnostic thresholds including the correct diagnosis of melanoma, classification of lesions as ‘atypical’ or ‘typical, and the decision to refer or to excise a lesion.Referral accuracy data comparing teledermatology against a face-to-face reference standard suggested good agreement for lesions considered to require some positive action by face-to-face assessment. For lesions considered of less concern when assessed face-to-face eg for lesions not recommended for excision or referral agreement was more variable with teledermatology specificities ranging from 57% (95% CI 39% to 73%)to 100% (95% CI 86% to 100%), suggesting that remote assessment is more likely recommend excision, referral or follow-up compared to in-person decisions.

Authors’ Conclusions: Studies were generally small and heterogeneous and methodological quality was difficult to judge due to poor reporting. Bearing in mind concerns regarding the applicability of study participants and of lesion image acquisition in specialist settings, our results suggest that teledermatology can correctly identify the majority of malignant lesions. Using a more widely defined threshold to identify possibly malignant cases or lesions that should be considered for excision is likely to appropriately triage those lesions requiring face-to-face assessment by a specialist. Despite the increasing use of teledermatology on an international level, the evidence base to support its ability to accurately diagnose lesions and to triage lesions from primary to secondary care is lacking and further prospective and pragmatic evaluation is needed.

Clark et al (2018) [Systematic Review]Systematic review of mobile
phone-based teledermatology8

Teledermatology is an expanding field within dermatology that has grown and become more clinically accepted by both patients and doctors. With approximately 260 million mobile phone users in the US and 4-6 billion worldwide with access to mobile phones, teledermatology serves as a potentially useful tool for diagnosis and management. In this review, we provide a detailed overview of mobile phone technology and the accumulating evidence for its incorporation into dermatology. Key questions addressed include accuracy and concordance between mobile teledermatology and face-to-face dermatology for the diagnosis of skin conditions. Similarly, accuracy and concordance were compared for the management of skin conditions. To track the development of mobile phone technology, we also assessed how data were captured, stored, and displayed in teledermatology studies.

Mounessa et al (2018) [Systematic Review] A systematic review of
satisfaction with teledermatology

Background: The two most commonly used modalities of teledermatology (TD) are store-and-forward (SF) and live-interactive (LI) TD. Existing studies have not compared these tools with respect to patient and provider satisfaction. Objective: To systematically review all published studies of patient and provider satisfaction with SF and LI TD. Methods PubMed, EMBASE, and Cochrane databases were systematically searched for studies on provider or patient satisfaction with SF or LI TD between January 2000 and June 2016. Results: Forty eligible studies were identified: 32 with SF TD, 10 with LI TD, and 2 evaluating both. With SF TD, 96% of studies assessing patient satisfaction and 82% of studies assessing provider satisfaction demonstrated satisfaction (n = 24 and 17, respectively). With LI TD, 89% of studies assessing patient satisfaction and all studies assessing provider satisfaction revealed satisfaction (n = 9 and 6, respectively). Conclusion: Patients and providers are satisfied with both SF and LI TD. Studies assessing satisfaction with LI have not been conducted in recent years, and have only been conducted in limited geographic patient populations. Further research assessing satisfaction with TD will help address any dissatisfaction with its uses and allow for increased support and funding of future programmes.

Svendsen et al (2018) [Systematic Review] eHealth Technologies as an intervention to improve adherence to topical antipsoriatics: a systematic review10

Background: Topical antipsoriatics are recommended first-line treatment of psoriasis, but rates of adherence are low. Patient support by use of electronic health services is suggested to improve medical adherence. Objective: To review randomised controlled trials (RCTs)testing eHealth interventions designed to improve adherence to topical antipsoriatics and to review applications for smartphones incorporating the word psoriasis. Results: Only one RCT was included, reporting on psoriasis patients’ Internet reporting their status of psoriasis over a 12-month period. The rate of adherence was measured by Medication Event Monitoring System (MEMS® ). An improvement in medical adherence and reduction of severity of psoriasis were reported. A total 184 apps contained the word psoriasis were found. Conclusion: There is a critical need for high-quality RCTs testing if the ubiquitous eHealth technologies, for example, some of the numerous apps, can improve psoriasis patients’ rates of adherence to topical antipsoriatics.

Finnane et al (2017) [Systematic Review] Teledermatology for the
Diagnosis and Management of Skin Cancer: A Systematic Review11

Importance: As technology becomes more commonplace in dermatological practice, it is essential to continuously review the accuracy of teledermatology devices and services compared with in-person care. The last systematic review was conducted over 5 years ago. Objective: To synthesize and assess the quality of the evidence to address 3 research questions: 1.How accurate is teledermatology for skin cancer diagnosis compared with usual care [FTFdiagnosis]? 2.Does teledermatology save clinician and/or patient time, compared with usual care? 3.What are the enablers and barriers to adoption of teledermatology in clinical practice for the diagnosis of skin cancer? Evidence Review: The review protocol was registered in the PROSPERO database. Six databases Cochrane, PubMed, Medline, Science Direct, Embase, and Web of Science were searched for studies investigating the diagnostic accuracy and concordance, management accuracy and concordance, measures of time, and enablers and barriers to implementation. Potentially eligible articles were screened by 2 reviewers. The QUADAS-2 tool was used to evaluate the risk of bias and applicability of individual studies assessing diagnostic accuracy.

Findings: Twenty-one studies were reviewed. The diagnostic accuracy defined as agreement with histopathology for excised lesions or clinical diagnosis for nonexcised lesions of FTF dermatology consultation remains higher (67%-85% agreement with reference standard, Cohen κ, 0.90) when compared with teledermatology (51%-85% agreement with reference standard, κ, 0.41-0.63), for the diagnosis of skin cancer. However, some studies do report high accuracy of teledermatology diagnoses. Most studies of diagnostic accuracy and concordance had significant methodological limitations. Studies of health service outcomes found teledermatology reduced waiting times and could result in earlier assessment and treatment. Patients reported high satisfaction and were willing to pay out of pocket for access to such services. Conclusions and Relevance: Robust implementation studies of teledermatology are needed, paying careful attention to reducing risk of bias when assessing diagnostic accuracy. Teledermatology services consistently reduced waiting times to assessment and diagnosis, and patient satisfaction was high.

Vyas et al (2017) [Systematic Review] A Systematic Review of the Use of Telemedicine in Plastic and Reconstructive Surgery and Dermatology12

Background: Telemedicine, the use of information technology and telecommunication to provide healthcare at a distance, is a burgeoning field with applications throughout medicine. Given the visual nature of plastic surgery and dermatology, telemedicine has a myriad of potential applications within the field. Methods: A comprehensive literature review of articles published on telemedicine since January 2010 was performed. Articles were selected for their relevance to plastic and reconstructive surgery and dermatology, and then reviewed for their discussion of the applications, benefits, and limitations of telemedicine in practice. Results: A total of 3119 articles were identified in the initial query. Twentythree articles met the inclusion criteria in plastic surgery: 7 wound management, 5 burn management, 5 trauma, 4 free flap care, 2 in cleft lip/palate repair. Twenty-three (100%) reported a benefit of telemedicine often related to improved postoperative monitoring, increased access to expertise in rural settings, and cost savings, either predicted or actualized. Eight (35%) reported limitations and barriers to the application of telemedicine, including overdiagnosis and dependence on functional telecommunication systems. Sixty-six articles focused on telemedicine in dermatology and also demonstrated significant promise. Conclusions: Telemedicine holds special promise in increasing the efficiency of postoperative care for microsurgical procedures, improving care coordination and management of burn wounds, facilitating interprofessional collaboration across time and space, eliminating a significant number of unnecessary referrals, and connecting patients located far from major medical centers with professional expertise without impinging on-and in some cases improving-the quality or accuracy of care provided.

Teledermatology consultation was found to be safe and has a comparable or superior efficacy to the traditional in-patient consultation. The system was consistently rated as convenient and easy to use by patients, referring physicians, and consulting dermatologists. Teledermatology has also been used as an educational tool for patients. A significant number of studies detailed strategies to improve the current state of teledermatology, either by implementing new programs or improving technologies. Telemedicine use is widespread among plastic surgeons and is enabling the spread of expertise beyond major medical centers. Further research is needed to conclusively demonstrate benefit in routine clinical care.

Randomised Controlled Trials

Janda et al (2020) [Randomised Controlled Trial]Accuracy of mobile digital teledermoscopy for skin self-examinations in adults at high risk of skin cancer: an open-label, randomised controlled trial13

Skin self-examinations supplemented with mobile teledermoscopy might improve early detection of skin cancers compared with naked-eye skin selfexaminations. We aimed to assess whether mobile teledermoscopyenhanced skin self-examination can improve sensitivity and specificity of self-detection of skin cancers when compared with naked-eye skin selfexamination. Methods: This randomised, controlled trial was done in Brisbane, Australia. Eligible participants aged ≥18 years had at least two skin cancer risk factors as self-reported in the eligibility survey and had to own or have access to an iPhone compatible with a dermatoscope attachment iPhone versions 5–8. Participants were randomly assigned (1:1), via a computer-generated randomisation procedure, to the intervention group [mobile dermoscopyenhanced self-skin examination] or the control group [naked-eye skin self-examination]. Control group and intervention group participants received web-based instructions on how to complete a whole body skin self-examination. All participants completed skin examinations at baseline, 1 month, and 2 months; intervention group participants submitted photographs of suspicious lesions to a dermatologist for telediagnosis after each skin examination and control group participants noted lesions on a body chart that was sent to the research team after each skin examination. All participants had an in-person whole-body clinical skin examination within 3 months of their last skin self-examination. Primary outcomes were sensitivity and specificity of skin self-examination, patient selection of clinically atypical lesions suspicious for melanoma or keratinocyte skin cancers [body sites examined, number of lesions photographed, types of lesions, and lesions missed], and diagnostic concordance of telediagnosis versus in-person whole-body clinical skin examination diagnosis. All primary outcomes were analysed in the modified intention-to-treat population, which included all patients who had a clinical skin examination within 3 months of their last skin self-examination. This trial was registered with the Australian and New Zealand Clinical Trials Registry, ACTRN12616000989448.

Findings: Between March 6, 2017, and June 7, 2018, 234 participants consented to enrol in the study, of whom 116 (50%) were assigned to the intervention group and 118 (50%) were assigned to the control group. 199 participants (98 participants in the intervention group and 101 participants in the control group) attended the clinical skin examination and thus were eligible for analyses. Participants in the intervention group submitted 615 lesions (median 6·0 per person; range 1–24)for telediagnosis and participants in the control group identified and recorded 673 lesions (median 6·0 per person; range 1–16). At the lesion level, sensitivity for lesions clinically suspicious for skin cancer was 75% (95% CI 63–84)in the intervention group and 88% (95% CI 80–91)in the control group (p=0·04). Specificity was 87% (95% CI 85–90)in the intervention group and 89% (95% CI 87–91)in the control group (p=0·42). At the individual level, the intervention group had a sensitivity of 87% (95% CI 76–99) compared with 97% (95% CI 91–100)in the control group (p=0·26), and a specificity of 95% (95% CI 90–100) compared with 96% (95% CI 91–100)in the control group. The overall diagnostic concordance between the telediagnosis and in-person clinical skin examination was 88%. Interpretation: The use of mobile teledermoscopy did not increase sensitivity for the detection of skin cancers compared with naked-eye skin self-examination; thus, further evidence is necessary for inclusion of skin self-examination technology for public health benefit.

Walter et al (2020) [Randomised Controlled Trial] Effect of a Skin Selfmonitoring Smartphone Application on Time to Physician Consultation Among Patients With Possible Melanoma: A Phase 2 Randomized Clinical Trial14

Importance: Melanoma is among the most lethal skin cancers; it has become the fifth most common cancer in the UK, and incidence rates are rising. Population approaches to reducing incidence have focused on mass media campaigns to promote earlier presentation and potentially improve melanoma outcomes; however, interventions using smartphone applications targeting those with the greatest risk could promote earlier presentation to health care professionals for individuals with new or changing skin lesions.

Objective: To study the effect of a commercially available skin self-monitoring (SSM) smartphone application among individuals with increased risk of melanoma on their decision to seek help for changing skin lesions. Design, setting, and participants: This phase 2 randomized clinical trial was conducted in 12 family practices in Eastern England between 2016 and 2017. A total of 238 participants, aged 18 to 75 years and with an increased risk of melanoma, were identified using a real-time melanoma risk assessment tool in family practice waiting rooms. Analysis was intention to treat. Participants were observed for 12 months, and data analysis was conducted from January to August 2018. Intervention: The intervention and control groups received a consultation with standard written advice on sun protection and skin cancer detection. The intervention group had an SSM application loaded on their smartphone and received instructions for use and monthly self-monitoring reminders. Main Outcomes and Measures: The coprimary outcomes were skin consultation rates with family practice physicians and patient intervals, measured as the time between noticing a skin change and consulting with a family practice clinician. Follow-up questionnaires were sent at 6 and 12 months, and consultation rates were extracted from family practice records.

Secondary Outcomes: included skin self-examination benefits and barriers, self-efficacy for consulting without delay, perceived melanoma risk, sun protection habits, and potential harms. Results: A total of 238 patients were randomized (median [interquartile range] age, 55 [43-65] years, 131 [55.0%] women, 227 [95.4%] white British; 119 [50.0%] randomized to the intervention group). Overall, 51 participants (21.4%) had consultations regarding skin changes during the 12 months of follow-up, and 157 participants (66.0%) responded to at least 1 follow-up questionnaire. There were no significant differences in skin consultation rates (adjusted risk ratio, 0.96; 95% CI, 0.56 to 1.66; P = .89), measures of SSM (adjusted mean difference, 0.08; 95% CI, -0.83 to 1.00; P = .86), or psychological harm (eg Melanoma Worry Scale: adjusted mean difference, – 0.12; 95% CI, -0.56 to 0.31; P = .58). Conclusions and Relevance: In this study, recruitment, retention, and initial delivery of the intervention were feasible, and this research provided no evidence of harm from the SSM smartphone application. However, no evidence of benefit on skin self-examination or health care consulting was found, and there is no reason at this stage to recommend its implementation in this population at increased risk of melanoma.

Ford et al (2019) [Randomised Controlled Trial] Access to Dermatological Care with an Innovative Online Model for Psoriasis Management: Results from a Randomized Controlled Trial15

Background: Many patients with chronic skin diseases lack regular access to dermatologists in the United States and suffer poor clinical outcomes. Introduction:We performed a 12-month randomized controlled trial to evaluate the impact of an online, collaborative connected health (CCH) model for psoriasis management on access to specialty care. Materials and Methods: The 300 enrolled patients were randomized to online or in-person care. We compared distance traveled as well as transportation and in-office waiting time between the two groups and obtained patient and provider perspectives on CCH. Results:At baseline, no differences existed between the groups in difficulties obtaining specialty care.Over 12 months, the mean distance traveled to and from appointments was 174.8 (±577.4) km/person for the in-person group and 2.2 (±14.2) km/person for the online group (p = 0.0003). The mean (SD) time spent on transportation and in-office waiting for in-person appointments was 4.0 (±4.5) h/person for the in-person group and 0.1 (±0.4) h/person for the online group (p = 0.0001). Patients found CCH to be safe, accessible, equitable, efficient, effective, and patient-centered. Providers found CCH to be useful for providing psoriasis care. Discussion: The CCH model resulted in significantly less distance traveled as well as transportation and in-office waiting time compared to in-person care. Both patients and providers were highly satisfied with CCH. Conclusions: The CCH model resulted in increased access to specialty care and enabled patient-centered, safe, and effective management of psoriasis patients.

Young et al (2019) [Randomised Controlled Trial] Effects of Online Care on Functional and Psychological Outcomes in Patients with Psoriasis: A Randomized Controlled Trial16

Background: The impact of online care on patients’ functional and psychological outcomes is critical to determine yet still unknown. Objective: To evaluate how a novel online health model that facilitates physician-patient collaboration compares with in-person care for improving psoriasis patients’ functional status and mental health. Methods: This 12-month randomized controlled equivalency trial randomized psoriasis patients 1:1 to online or in-person care. Functional impairment and depression were assessed at baseline and at 3-month intervals using the 5-level EuroQol-5 Dimensions (EQ-5D-5L) and Patient Health Questionnare-9 (PHQ-9). Results: 296 patients were randomized to online or in-person groups. The between-group difference in overall improvement in EQ VAS (EuroQol Visual Analogue Scale) was -0.002 (95% CI -2.749, 2.745), falling within equivalence margin ±8. The between-group difference in overall improvement in EQ-5D5L index was 0 (95% CI -0.003, 0.003), falling within equivalence margin ±0.1. The between-group difference in overall improvement in PHQ-9 was -0.33 (95% CI -1.20, 0.55), falling within equivalence margin ±3. Limitations: Slightly different attrition rates between online and in-person arms (11% versus 9%), but no impact on outcomes. Conclusion: The online health model was equivalent to in-person care for reducing functional impairment and depressive symptoms in psoriasis patients.

Armstrong et al (2018) [Randomised Controlled Trial] Effectiveness of Online vs In-Person Care for Adults With Psoriasis: A Randomized Clinical Trial17

Importance: Innovative, online models of specialty-care delivery are critical to improving patient access and outcomes. Objective: To determine whether an online, collaborative connected-health model results in equivalent clinical improvements in psoriasis compared with in-person care. Design, Setting, and Participants: The Patient-Centered Outcomes Research Institute Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to evaluate the effect of an online model for psoriasis compared with in-person care. Participant recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California, and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a primary care physician. Analyses were on an intention-to-treat basis.

Interventions: Participants were randomized 1:1 to receive online or inperson care (148 randomized to online care and 148 randomized to in-person care). The online model enabled patients and primary care physicians to access dermatologists online asynchronously. The dermatologists provided assessments, recommendations, education, and prescriptions online. The inperson group sought care in person. The frequency of online or in-person visits was determined by medical necessity. All participants were exposed to their respective interventions for 12 months. Main outcomes and measures: The prespecified primary outcome was the difference in improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the online and in-person groups. Prespecified secondary outcomes included body surface area (BSA) affected by psoriasis and the patient global assessment score. Results: Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person groups in the mean change in the self-administered PASI score during the 12-month study period was – 0.27 (95% CI, -0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis between the 2 groups was -0.05% (95% CI, -1.58% to 1.48%). Between-group differences in the PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence between the 2 interventions. The difference in the mean change in the patient global assessment score between the 2 groups was -0.11 (95% CI, – 0.32 to 0.10), which exceeded the equivalence margin, with the online group displaying greater improvement.

Conclusions and relevance: The online, collaborative connected-health model was as effective as in-person management in improving clinical outcomes among patients with psoriasis. Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be transformative to improving patient-centered outcomes in chronic diseases.

Bosanac et al (2018) [Randomised Controlled Trial] Randomized and controlled pilot study of the pragmatic use of mobile phone based follow up of actinic keratoses treated with topical 5fluorouracil18

Store-and-forward teledermatology involves transmission of a patient’s images to a healthcare provider and subsequent response from the provider about the diagnosis or management. Furthermore, teledermatology in which mobile phones are utilized for communication between the patient and their provider is referred to as mobile-teledermatology. In this study, we investigate the use of mobile-teledermatology in the management of actinic keratoses. We demonstrate that mobile-teledermatology may enhance communication between the patient and their provider when managing cutaneous disease and that even individuals in older age groups are highly satisfied with this type of follow up.

Marek et al (2018) [Randomised Controlled Trial] Piloting the Use of Smartphones, Reminders, and Accountability Partners to Promote Skin Self-Examinations in Patients with Total Body Photography: A Randomized Controlled Trial19

Objective: The aim of this study was to evaluate the use of a mobile application in patients already using total body photography (TBP) to increase skin self-examination (SSE) rates and pilot the effectiveness of examination reminders and accountability partners. Design: Randomized controlled trial with computer generated randomization table to allocate interventions. Setting: University of Pennsylvania pigmented lesion clinic. Participants: 69 patients aged 18 years or older with an iPhone/iPad, who were already in possession of TBP photographs. Intervention: A mobile app loaded with digital TBP photos for all participants, and either 1. the mobile app only; 2. skin examination reminders; 3. an accountability partner; or 4. remnders and an accountability partner. Main Outcome Measure: Change in SSE rates as assessed by enrollment and end-of-study surveys 6 months later. Results: Eighty-one patients completed informed consent, however 12 patients did not complete trial enrollment procedures due to device incompatibility, leaving 69 patients who were randomized and analyzed [mean age 54.3 years, standard deviation 13.9]. SSE rates increased significantly from 58% at baseline to 83% at 6 months (odds ratio 2.64, 95% confidence interval 1.20-4.09), with no difference among the intervention groups. The group with examination reminders alone had the highest (94%) overall satisfaction, and the group with accountability partners alone accounted for the lowest (71%). Conclusion: A mobile app alone, or with reminders and/or accountability partners, was found to be an effective tool that can help to increase SSE rates. Skin examination reminders may help provide a better overall experience for a subset of patients.

Svendsen et al (2018) [Randomised Controlled Trial] A smartphone application supporting patients with psoriasis improves adherence to topical treatment: a randomized controlled trial20

Background: Adherence to topical psoriasis treatments is low, which leads to unsatisfactory treatment results. Smartphone applications for patient support exist but their potential to improve adherence has not been systematically evaluated. Objectives: To evaluate whether a study-specific app improves adherence and reducespsoriasis symptoms compared with standard treatment. Methods: We conducted a randomized controlled trial. Patients received once-daily medication [calcipotriol/betamethasone dipropionate (Cal/BD) cutaneous foam] and were randomized to no app (n = 66) or app intervention (n = 68) groups. In total, 122 patients (91%) completed the 22-week followup. The primary outcome was adherence, which was defined as medication applied ≥ 80% of days during the treatment period and assessed by a chip integrated into the medication dispenser. Secondary outcomes were psoriasis severity measured by the Lattice System Physician’s Global Assessment (LS-PGA) and quality of life, measured using the Dermatology Life Quality Index (DLQI) at all visits. Results: Intention-to-treat analyses using regression was performed. More patients in the intervention group were adherent to Cal/BD cutaneous foam than those in the nonintervention group at week 4 (65% vs. 38%, P = 0·004). The intervention group showed a greater LS-PGA reduction than the nonintervention group at week 4 (mean 1·86 vs. 1·46, P = 0·047). A similar effect was seen at weeks 8 and 26, although it did not reach statistical significance. Conclusions: This RCT demonstrates that the app improved short-term adherence to Cal/BD cutaneous foam treatment and psoriasis severity.

Ferrandiz et al (2017) [Randomised Controlled Trial] Internet-based skin cancer screening using clinical images alone or in conjunction with dermoscopic images: A randomized teledermoscopy trial21

Background: Teledermoscopy involves the use of dermoscopic images for remote consultation and decision-making in skin cancer screening. Objective: We sought to analyze the potential benefits gained from the addition of dermoscopic images to an internet-based skin cancer screening system. Methods: A randomized clinical trial assessed the diagnostic performance and cost-effectiveness of clinical teleconsultations (CTC) and clinical with dermoscopic teleconsultations. Results: A total of 454 patients were enrolled in the trial. Teledermoscopy improved sensitivity and specificity (92.86% and 96.24%, respectively) compared with CTC (86.57% and 72.33%, respectively). Correct decisions were made in 94.30% of patients through clinical with dermoscopic teleconsultations and in 79.20% in CTC (P < .001). The only variable associated with an increased likelihood of correct diagnosis was management using teledermoscopy (odds ratio 4.04; 95% confidence interval 2.02-8.09; P < .0001). The cost-effectiveness analysis showed teledermoscopy as the dominant strategy, with a lower cost-effectiveness ratio (65.13 vs 80.84). Limitations: Potentially, a limitation is the establishment of an experienced dermatologist as the gold standard for the in-person evaluation. Conclusions: The addition of dermoscopic images significantly improves the results of an internet-based skin cancer screening system, compared with screening systems based on clinical images alone.

Gernart et al (2017) [Randomised Controlled Trial] ItchApp©: An Appbased eDiary for Assessment of Chronic Pruritus in Clinical Trials22

Performing a reliable assessment of chronic pruritus remains a challenge. Electronic diaries are often used, but many of the scales have not been validated. ItchApp© was developed for Android smartphones in order to address this lack. A total of 40 subjects with chronic pruritus completed questionnaires both on paper and with ItchApp© (verbal rating scale, numerical rating scale, dynamic pruritus score)in order to validate the software application. Strong correlations were found for test-retest reliability (intraclass correlation coefficient: 0.865-0.977) and convergent validity (Spearman’s r: 0.442-0.924). A feasibility questionnaire for ItchApp© revealed a high level of user friendliness and compliance. This was confirmed in a randomized controlled trial with 68 subjects, for which the clinically important difference in the numerical rating scale values for ItchApp© was calculated (2.61 points). In summary, ItchApp© is a recently developed eDiary that can provide experts with a reliable evaluation of patients with chronic pruritus. It will be made available for future clinical trials.

Kornmehl et al (2017) [Randomised Controlled Trial] Direct-Access Online Care for the Management of Atopic Dermatitis: A Randomized Clinical Trial Examining Patient Quality of Life23

Background: Atopic dermatitis (AD)is a chronic disease requiring regular follow-up. To increase access to dermatological care, online management of AD is being studied. However, a critical knowledge gap exists in determining AD patients’ quality of life in direct-to-patient online models. In this study, we examined quality of life in AD patients managed through a direct-access online model. Materials and Methods: We randomized 156 patients to receiving care through a direct-access online platform or in person. Patients were seen for six visits over 12 months. At each visit, the patients completed Dermatology Life Quality Index/Children’s Dermatology Life Quality Index (DLQI/CDLQI), and Short Form (SF-12). Results: Between baseline and 12 months, the mean (standard deviation, SD) within-group difference in DLQI score in the online group was 4.1 (±2.3); for the in-person group, the within-group difference was 4.8 (±2.7). The mean (SD) within-group difference in CDLQI score in the online group was 4.7 (±2.8); for the in-person group, the within-group difference was 4.9 (±3.1). The mean (SD) within-group difference in physical component score (PCS) and mental component score (MCS) SF-12 scores in the online group was 6.5 (±3.8) and 8.6 (±4.3); for the in-person group, it was 6.8 (±3.2) and 9.1(±3.8), respectively. The difference in the change in DLQI, CDLQI, SF-12 PCS, and SF12 MCS scores between the two groups was 0.72 (95% confidence interval [90% CI], -0.97 to 2.41), 0.23 (90% CI, -2.21 to 2.67), 0.34 (90% CI, -1.16 to 1.84), and 0.51 (90% CI, -1.11 to 2.13), respectively. All differences were contained within their equivalence margins. Conclusion: Adult and pediatric AD patients receiving direct-access online care had equivalent quality of life outcomes as those see in person. The direct-access online model has the potential to increase access to care for patients with chronic skin diseases.

Piette et al (2017) [Randomised Controlled Trial] Impact of a store-and forward teledermatology intervention versus usual care on delay before beginning treatment: A pragmatic cluster-randomized trial in ambulatory care24

Introduction: In France, 66% of patients forego getting specialized care by dermatologists because of difficulty obtaining appointments. Store-and-forward teledermatology could improve how promptly treatment begins by reducing the delay in obtaining a specialist’s opinion. In this study, we compared the delay before care between general practitioners using a storeand-forward teledermatology intervention and GPs addressing their patients with a standard referral letter. Methods: We performed an open-label, pragmatic cluster-randomized controlled trial with two parallel arms. GP clinics in Paris were randomly assigned to use either teledermatology referral [use of electronics to send clinical images taken using a mobile phone] or conventional referral [using standard letters]to care for patients for whom a dermatologist’s advice was needed for the diagnosis or treatment of skin lesions. Dermatologists integrated responses to teledermatology requests in their usual schedule. Patients were followed up for three months. Primary outcome was the delay, in days, between the GP’s consultation and a reply by the specialist allowing treatment to begin. Analyses were adjusted for clustering of GPs and identities of dermatologists. Results: Between February and June 2014, 103 patients were included in the study (53 patients of 20 GPs in the intervention group). The median delay between the initial GP’s consultation and the reply allowing for treatment to begin was four days in the intervention group and 40 days in the control group (adjusted hazard ratio = 2.55; p < 0.011). Discussion: We showed that a simple store-and-forward teledermatology intervention significantly reduced the delay before beginning care.

Armstrong et al (2015) [Randomised Controlled Trial] Patient-centered, direct-access online care for management of atopic dermatitis: a randomized clinical trial25

Importance: New models of health care delivery for dermatological care have the potential to increase access and improve patient-centered outcomes. Objective: To compare effectiveness of a direct-access, online model for follow-up dermatologic care in pediatric and adult patients with atopic dermatitis with that of in-person office visits. Design, setting, and participants: This was a 1-year, randomized controlled equivalency clinical trial in medically under-served areas, outpatient clinics, and the general community. Participants included children and adults with atopic dermatitis with access to the Internet, computers, and digital cameras. Interventions: After an initial in-person visit, patients were randomized 1:1 to direct-access online or usual in-person care for follow-up management of atopic dermatitis. In the direct-access online group, patients captured and transmitted clinical images and history asynchronously to dermatologists online; dermatologists evaluated the clinical information, provided recommendations and education, and prescribed medications online asynchronously. In the in-person group, patients visited dermatologists in their offices for follow-up care. Main Outcomes and Measures: Atopic dermatitis disease severity as assessed by patient-oriented eczema measure (POEM) and investigator global assessment (IGA).

Results: A total of 156 children and adults were randomized. Between baseline and 12 months, the mean (SD) within-group difference in POEM score in patients in the direct-access online group was -5.1 (5.48)(95% CI, – 6.32 to -3.88); in the in-person group, the within-group difference was -4.86 (4.87)(95% CI, -6.27 to -3.46). The difference in the change in POEM scores between the 2 groups was 0.24 (6.59)(90% CI, -1.70 to 1.23), which was contained within the predetermined 2.5 equivalence margin. The percentage of patients achieving clearance or near-clearance of their disease (IGA score of 0 or 1) was 38.4% (95% CI, 27.7% to 49.3%)in the direct-access online group and 43.6% (95% CI, 32.6%-54.6%)in the in-person group. The difference in the percent of patients achieving clearance or near-clearance between the 2 groups was 5.1% (90% CI, 1.7%-8.6%), which was contained within the predetermined 10% equivalence margin. Conclusions and Relevance: The direct-access online model results in equivalent improvements in atopic dermatitis clinical outcomes as in-person care. Direct-access online care may represent an innovative model of delivering dermatological services to patients with chronic skin diseases.

Fruhauf et al (2015) [Randomised Controlled Trial]Mobile teledermatology helping patients control high-need acne: a randomized controlled trial26

Background: Acne is an important health issue with a major psychological impact in addition to the physical problems it causes. Objectives: To investigate the superiority of mobile teledermatology in the care of patients with high-need facial acne in comparison to outpatient services with particular attention to treatment efficacy, safety, and patient compliance. Further, patient satisfaction with remote care was evaluated. Methods: Sixty-nine consecutive patients (f: 25, m: 44, median age: 19 years, range: 13-37 years) were randomly allocated to either the teleconsultation (TCA) or the outpatient consultation (OCA) arm of the trial to receive isotretinoin treatment in weight and severity-dependent dosages over 24 weeks. Acne grading was performed by one examiner using the Global Acne Severity Scale (GEA) and the total lesion counting (TLC). Results: Due to noncompliance issues, 17 of 69 (24.6%) patients were excluded from the study, of who 10 had been assigned to the TCA (10/34; 29.4%) and 7 to the OCA (7/35; 20%). Both, in the TCA (GEA-score: ∆ = 2.25; TLC: ∆ = 89.08) and in the OCA (GEA-score: ∆= 2.0; TLC: ∆= 91.21) excellent and almost equivalent therapeutic outcomes were achieved. In the TCA, however, less patients experienced adverse reactions (P = 0.55). Even though additional live supervision would have been appreciated in some teledermatology cases, patients were satisfied with the mobile service and no consultation request was created. Conclusion: Mobile teledermatology is an efficient, safe and well-accepted tool among patients with high-need acne constituting at least a valuable adjunct to outpatient care services. Further larger studies would be useful to confirm our findings.


Abbott et al (2020) Practice guidelines for teledermatology in Australia27

Despite the potential of teledermatology to increase access to dermatology services and improve patient care, it is not widely practised in Australia. In an effort to increase uptake of teledermatology by Australian dermatologists and support best practice, guidelines for teledermatology for the Australian context have been developed by The University of Queensland’s Centre for Online Health in collaboration with The Australasian College of Dermatologists’ E-Health Committee. The guidelines are presented in two sections: 1. Guidelines and 2. Notes to support their application in practice, when feasible and appropriate. Content was last updated March 2020 and includes modalities of teledermatology; patient selection and consent; imaging; quality and safety; privacy and security; communication; and documentation and retention of clinical images. The guidelines educate dermatologists about the benefits and limitations of telehealth while articulating how to enhance patient care and reduce risk when practicing teledermatology.

Abbott et al (2020) A review of literature supporting the development of practice guidelines for teledermatology in Australia28

Despite the potential of teledermatology to increase access to dermatology services and improve patient care, it is not widely practised in Australia. In an effort to increase uptake of teledermatology, Australian-specific practice guidelines for teledermatology are being developed by the Australasian College of Dermatologist. This paper reports finding from literature reviews that were undertaken to inform the development of these guidelines. Results cover the following sections: Modalities of teledermatology; Patient selection and consent; Imaging; Quality and safety; Privacy and security; Communication; and Documentation and retention. The document educates providers about the benefits and limitations of telehealth while articulating how to enhance patient care and reduce risk when practicing teledermatology.

Abbott and Soyer (2020)A CLOSE‐UP guide to capturing clinical images29

Telemedicine is rapidly becoming ubiquitous as the medical profession adjusts its practice to provide optimal care to patients in the context of the COVID-19 pandemic. The ability to provide accurate dermatological advice via telemedicine is dependent on the receipt of high-quality clinical images and accurate clinical context, on which clinicians receive little education during medical school and subsequent training. Clinicians can improve their capture, delivery and storage of images using the CLOSE-UP acronym, which encapsulates important considerations in the clinical photography process.

Bianchi et al (2020) Benefits of Teledermatology for Geriatric Patients: Population-Based Cross-Sectional Study30

Background: Teledermatology is a health care tool that has been increasingly used around the world, mostly because dermatology has an emphasis on visual diagnosis. Many studies have shown that access to specialized care improves using teledermatology, which provides accurate diagnosis and reduces the time taken for treatment, with high patient satisfaction. As the population around the world grows old, there will be even more demand for dermatologists in years to come. It is essential to know which are the most prevalent skin conditions in the primary care population and if they can be addressed through teledermatology. Objective: Our main goal was to evaluate the proportion of lesions in individuals aged 60 years and older that could be managed using teledermatology in conjunction with primary care physicians. Second, we aimed to assess the most frequent skin lesions, the most common treatments provided to patients, and the distribution and causes of referrals made by the teledermatologists.

Methods: This was a retrospective cohort study from July 2017 to July 2018 in São Paulo, Brazil. We included 6633 individuals aged 60 years and older who presented with 12,770 skin lesions. Teledermatologists had three options to refer patients: 1. to undergo biopsy directly; an in-person dermatologist visit; and 3. back to the primary care physician with the most probable diagnosis and treatment. Results: Teledermatology managed 66.66% (8408/12614) of dermatoses with the primary care physician without the need for an in-presence visit; 27.10% (3419/12614) were referred to dermatologists, and 6.24% (787/12614) directly to biopsy. The most frequent diseases were seborrheic keratosis, solar lentigo, onychomycosis, melanocytic nevus, benign neoplasms, actinic keratosis, epidermoid cyst, xerosis, leucoderma, and wart, with significant differences between sexes. Malignant tumors increased with age and were the leading cause for biopsies, while infectious skin conditions and pigmentary disorders decreased. Emollient was the most frequent treatment prescribed, in 31.88% (909/2856) of the cases.

Conclusions: Teledermatology helped to treat 67% of the dermatoses of older individuals, addressing cases of minor complexity quickly and conveniently together with the primary care physician, thus optimizing dermatological appointments for the most severe, surgical, or complex diseases. Teledermatology does not aim to replace a face-to-face visit with the dermatologist; however, it might help to democratize dermatological treatment access for patients and decrease health care expenses.

Brunasso and Massone (2020) Teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during COVID-19 emergency in a tertiary center in Italy31

Because of the coronavirus disease 2019 (COVID-19) emergency, on March 9, 2020 Italy went in lock-down imposing the closure of non-urgent outpatient clinics devoted to care of chronic, severe, inflammatory skin diseases that require periodic follow-up. In this emergency situation, due to the lack of a teledermatology platform and in order not to leave our vulnerable high-need patients without proper follow-up, we started a teledermatologic service in smartworking using phone calls and emails. The total number of patients scheduled was 195; in 12 cases, we were not able to talk to the patients. Remote monitoring was performed in 183 patients [126 moderate to severe psoriasis, 10 severe acne, 11 severe atopic dermatitis, 11 hidradenitis suppurativa, 9 blistering autoimmune diseases, and 16 other autoimmune skin diseases]. During remote-visits, several interventions were conducted: triage for COVID-19 suspected symptoms, email check of clinical pictures and of laboratory examinations, advices for topical and systemic therapy continuation or discontinuation/switch and reschedule of next appointment. Only five patients required personal office visit (2.7%), reducing consistently the number of face-to face visits. Our real-life experience shows that remote monitoring was effective in preventing unnecessary worsening of severe chronic skin diseases and poor outcomes due to withdrawal of current therapy.

Corden et al (2020)A targeted response to the COVID-19 pandemic:
analysing effectiveness of remote consultations for triage and
management of routine dermatology referrals32

When the UK entered lockdown in March 2020 amidst the COVID-19 pandemic, routine dermatology work was suspended as per national guidance to allow for redeployment of staff to the front line and also reducing risk of patient exposure and travel. New patient referrals from primary care into dermatology services usually enter via one of three routes:1. two week wait for suspected serious skin malignancies; 2. routine non-urgent cases; and 3. emergency referrals via an on call service. All these patients are assessed via a face-to-face consultation, after various waiting times depending on their urgency. As a result of this suspension just over 800 new routinely referred patients had their appointments temporarily suspended, covering a six week period. Many of these patients had already waited up to 18 weeks for an initial assessment. Furthermore, with the dual challenge of a depleted dermatology workforce and the need for reduced face-to-face consultations during the lock-down, it became imperative to develop new solutions to ensure this cohort of patients would receive care within an appropriate time-frame. To evaluate our response to this challenge we prospectively collected data, with the aim to investigate whether the strategy deployed was an efficient way of assessing this large number of referred patients. We also initiate discussion as to whether this novel method of working could yield a framework for providing a future dermatology service in the event of prolonged social distancing.

Dobry et al (2020)Implementation and Impact of a Store-and-Forward Teledermatology Platform in an Urban Academic Safety-Net Health Care System33

Background: Minority and low-income patients disproportionately experience dermatologic access challenges. Store-and-forward (SAF) teledermatology has emerged as a model of care delivery that may improve access. We sought to evaluate patterns of utilization and overall impact after SAF teledermatology implementation in a safety-net health care system. Methods:We performed a retrospective review of 3,285 teledermatology consultations from 2014 to 2017 in an urban academic safety-net health care system. Results:A total of 1,680 (51.2%) patients were referred for inflammatory/rash conditions and 967 (29.5%)for skin lesions. The teledermatologist recommended in-person evaluation in 1,199 encounters (36.5%). Median wait time for a subsequent appointment was 36 days (range 0-244 days). Of subsequent in-clinic visits, 237 patients (26.4%) underwent skin biopsy. No-show rate after referral was 11.8%. In comparison, median wait time for dermatology appointment through standard referral was 64 days, with a no-show rate of 18.6%. Biopsy rate of patients referred via teledermatology was 26.4%, in comparison to a rate of 10.9% of patients referred directly from primary care provider. Discussion: Implementation of SAF teledermatology in a safety-net health system resulted in avoidance of 63.5% potential dermatology visits. Consultation typically resulted in a change in suspected diagnosis or management plan. Rates of concordance between teledermatology consults and in-person evaluations were high. Median wait time was reduced by almost half, no-show rate was reduced ∼37%, and biopsy rate was more than double for teledermatology patients compared with standard referral. Conclusion: These findings suggest that SAF teledermatology may improve access to high-quality dermatologic care and increase clinic efficiencies for patients in safety-net health care systems.

Greenwald et al (2020)Real-world outcomes of melanoma surveillance using the MoleMap NZ telemedicine platform34

Background: MoleMap NZ is a novel New Zealand-based store-and-forward telemedicine service to detect melanoma. It uses expert review of total body photography and close-up and dermoscopic images of skin lesions that are suspicious for malignancy. Objective: The purpose of this study was to assess the effectiveness of MoleMap NZ as a melanoma early detection program. Methods: We conducted a review of 2108 melanocytic lesions recommended for biopsy/excision by MoleMap NZ dermoscopists between January 2015 and December 2016. Results: Pathologic diagnoses were available for 1571 lesions. Of these, 1303 (83%)lesions were benign and 260 (17%)lesions were diagnosed as melanoma, for a melanoma-specific benign:malignant ratio of 5.0:1. The number needed to biopsy to obtain 1 melanoma was 6. Among melanomas with available tumor thickness data (n = 137), 92% were <0.8 mm (range in situ to 3.1 mm), with in situ melanomas comprising 74%. Limitations: Only lesions recommended for excision were analyzed. Pathology results were available for 75% of these cases. Tumor thickness data were available for 53% of melanomas diagnosed. Conclusions: This real-world study of MoleMap NZ, a community-based teledermoscopy program, suggests that it has the potential to increase patients’ access to specialist expertise via telemedicine. Additional studies are needed to more accurately define its efficacy.

Hampton et al (2020) Usability testing of MySkinSelfie: a mobile phone application for skin self-monitoring35

Teledermatology generally involves doctors taking images of patients; however, patients increasingly want to own or have easy access to their health data. MySkinSelfie is a mobile phone application designed to improve the quality, consistency and accessibility of patient-held photos, and was developed to give patients the ability to generate and hold their own skin images to help guide their skin care. This study assessed the usability of this app in a cohort of patients attending a National Health Service Dermatology clinic. Patients were asked to use the app but were not given specific tasks to achieve. Of the 102 patients recruited, 32 downloaded the app and registered an account, 21 took at least one photo (median 5, range 1-103) and 19 completed the usability questionnaire. The majority of questionnaire respondents found the app easy to use but were more neutral on whether it really helped them to manage their skin problem. MySkinSelfie has been shown tobe easy to use. Self-monitoring of skin problems may be useful for a subset of patients, and this is likely to depend on diagnosis, age and other patient factors.

Horsham et al (2020) Is Teledermoscopy Ready to Replace Face-to-Face Examinations for the Early Detection of Skin Cancer? Consumer Views, Technology Acceptance, and Satisfaction with Care36

Background: Previous cross-sectional research indicates high acceptance of mobile teledermoscopy-enhanced skin self-examination (SSE) by consumers based on the technology acceptance model (TAM) domains: perceived usefulness, ease of use, compatibility, attitude and intention, subjective norms, facilitator, and trust. However, no study has assessed this outcome longitudinally among people who actually used the technology in their own homes. Methods: Participants were living in Brisbane, Australia, aged 18 years or older, and at high risk of skin cancer. Participants randomly assigned to the intervention group (n = 98) completed a self-administered questionnaire on mobile teledermoscopy acceptance for skin cancer detection both before use and after performing mobile teledermoscopy-enhanced SSE in their homes. The survey included a 25-item scale assessing seven TAM domains. Item scores ranged from 5 [strongly agree]to 1 [strongly disagree]. Participants also answered survey questions on satisfaction with use of teledermoscopy, and a 9-item Thoughts about Melanoma scale that measures cancer worry. Results: Participants were 19-73 years old, had high skin cancer risk, blue or grey eyes (53.1%), fair or very fair skin (88.8%), and previous skin cancer treatments (61.2%). Participants were more accepting of mobile teledermoscopy at baseline: mean TAM score of 4.15 (SE 0.05); their level of acceptance decreased significantly after teledermoscopy use: mean score 3.94 (SE 0.05; p = 0.001). In linear regression analysis, the decrease in TAM scores was similar across demographic and skin cancer risk categories. Ninety-two percent (n = 90) of participants agreed that mobile teledermoscopy was easy to use. The mean score of the Thoughts about Melanoma scale did not change significantly from baseline to follow-up. Conclusion: Consumers had high TAM scores before they used mobile teledermoscopy within a randomised control trial. At the end of the intervention period, TAM scores decreased, although participants’ average score still indicated “agreement” that mobile teledermoscopy was acceptable.

Kips et al (2020)Teledermatology in Belgium: a pilot study37

Background: Teledermatology, the application of telemedicine in the field of dermatology, can be a valuable tool to improve the efficiency of care in general practice. Objectives: In this pilot study, we implemented a teledermatology programme in Belgian context to assess the effect on referral rate and to evaluate the acceptability of teledermatology by clinicians and patients. Material and Methods: A store-and-forward teledermatology service between 12 general practitioners (GPs) and 3 academic dermatologists was evaluated for a period of 3-6 months. Clinicians and patients were questioned about satisfaction, benefits and barriers. Results: In total, 54 teledermatologic consultations were performed. The referral rate was reduced. Thirty-one teleconsulations were performed instead of physical referral, of which nine patients were actually referred. In 23 cases, performed for a second opinion, two more patients were referred on the dermatologist’s advice. All clinicians want to continue working with teledermatology. GPs highlighted the educational benefit, whereas dermatologists were interested in the triage effect and reduced referral rate. Patients indicated that teledermatology would encourage them to consult a GP sooner when experiencing dermatologic problems. Conclusion: Teledermatology proved to be a feasible and acceptable tool for both clinicians and patients. It also shows to be a valuable for triage and reducing unnecessary referrals. Considering the emergent pressure on health care in the next decades, teledermatology following GP selection could be useful for theBelgian health care system and deserves further elaboration in the search for effective tools to strengthen first line health care and streamline referral to secondary care.

Kong et al (2020)[Randomised Controlled Trial]Consumer Preferences for Skin Cancer Screening Using Mobile Teledermoscopy: A Qualitative Study38

Background: Mobile teledermoscopy is a rapidly advancing technology that promotes early detection and management of skin cancers. Whilst the use of teledermoscopy has proven to be effective and has a role in the detection of skin cancers, patients’ attitudes towards the multiple ways in which this technology can be utilised has not been explored. Methods: Data were obtained from a large randomised controlled trial comparing mobile teledermoscopy-enhanced skin self-examinations (SSEs) with naked-eye SSE. A semi-structured interview guide was developed by the investigators with questions focusing on people’s previous skin screening behaviours and 2 of the major pathways which can be utilised in mobile teledermoscopy: 1. direct-to-consumer; and 2. doctor-to-doctor. All interviews were tape-recorded and transcribed verbatim. Thematic analysis was undertaken by 2 independent researchers. Results: Twenty-eight participants were interviewed. Eighty-six percent of participants (n = 24/28) had previously had a clinical skin examination. Only 18% of participants (n = 5/28) visited the same doctor for each clinical skin examination. Five main themes were identified in the interviews that affected how people felt about the integration of mobile teledermoscopy into skin screening pathways: history of clinical skin examinations, continuity of the doctor-patient relationship, convenience of the direct-to-consumer teledermoscopy, expedited review enhancing the doctor-to-doctor setting and mobile teledermoscopy as a partner-assisted task. Conclusions: Overall mobile teledermoscopy was viewed positively for both direct-to-consumer and doctor-to-doctor interaction. Continuity of care in the doctor-patient relationship was not found to be a priority for clinical skin examination with most participants visiting several doctors throughout their clinical skin examination history.

Liu et al (2020) A deep learning system for differential diagnosis of skin diseases39

Skin conditions affect 1.9 billion people. Because of a shortage of dermatologists, most cases are seen instead by general practitioners with lower diagnostic accuracy. We present a deep learning system (DLS)to provide a differential diagnosis of skin conditions using 16,114 de-identified cases from a teledermatology practice serving 17 sites. The DLS distinguishes between 26 common skin conditions, representing 80% of cases seen in primary care, while also providing a secondary prediction covering 419 skin conditions. On 963 validation cases, where a rotating panel of three board-certified dermatologists defined the reference standard, the DLS was non-inferior to six other dermatologists and superior to six primary care physicians (PCPs) and six nurse practitioners (NPs)(top-1 accuracy: 0.66 DLS, 0.63 dermatologists, 0.44 PCPs and 0.40 NPs). These results highlight the potential of the DLS to assist general practitioners in diagnosing skin conditions.

Miller et al (2020) Real-time teledermatology clinics in a tertiary public hospital: A clinical audit40

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.

Nicholson et al (2020)Patient satisfaction with a new skin cancer
teledermatology service41

Background: Rising numbers of two-week-wait (2WW) skin cancer referrals have caused increasing pressure on UK dermatology departments. Initiatives to address this include teledermatology. Previous studies have indicated good patient acceptability but most have focused on general dermatology rather than skin cancer referrals, and have taken place in rural settings, where teledermatology may be preferable. Aim: To evaluate patient satisfaction of teledermatology 2WW services in a London-based tertiary National Health Service (NHS) setting. Methods: A literature search was performed and a patient satisfaction survey was designed to evaluate: 1. ease of completing a questionnaire about the skin lesion; 2. lifestyle impact; 3. preferences regarding electronic data collection and communication of results; and 4. confidence in the service. A five-point Likert scale was used to assess responses. The study took place over a 20-week period.

Results: Over half (51%; n = 31 of 60 patients) were female; 78% (47) were aged ≤ 55 years and 65% (39) were Caucasian. Over 80% (49) would recommend the service, and the majority felt confident with the teledermatology model. Overall, patients would be happy to complete electronic questionnaires and receive results electronically, with younger patients being more amenable to this. Patients with better health status, those of younger age and those with less frequent visits to a dermatologist were more accepting of teledermatology. Conclusion: To our knowledge, this is the first comprehensive study evaluating patient satisfaction with teledermatology specifically for 2WW referrals in an NHS setting. As skin cancer referrals increase, dermatology departments must adjust. Patient involvement and feedback is paramount in implementing and expanding teledermatology services.

Pasadyn et al (2020) Store-and-forward teledermatology impact on diagnosis, treatment and dermatology referrals: Comparison between practice settings42

Introduction: Store-and-forward (SAF)teledermatology involves nondermatologists sending clinical images to dermatologists. This improves patient care while reducing unwarranted face-to-face (FTF) specialist office visits. Comparisons between dermatologist diagnostic concordance with referring provider, treatment change recommendations, and FTF referrals have yet to be compared by type of provider and practice setting. Methods: This retrospective chart review examined SAF teledermatology eConsults from four practice settings: Doctor of Medicine (MD)/Doctor of Osteopathic Medicine (DO) office visits, MD/DO walk-in clinics, nurse practitioner (NP)/physician assistant (PA) office visits and NP/PA walk-in clinics. The most recent 100 MD/DO office- and 100 NP/PA walk-in-referred patient charts were reviewed. There were only 71 NP/PA office and 47 MD/DO walk-in eConsults to review.

Results: Teledermatologists agreed with referring provider diagnoses 50% of the time for MD/DO office visits, 29.8% for MD/DO walk-in clinics, 33.8% for NP/PA office visits and 34% for NP/PA walk-in clinics. Diagnostic concordance was significantly higher for eConsults from MD/DO office visits than MD/DO walk-in clinics (p = 0.021), NP/PA office visits (p = 0.035) or NP/PA walk-in clinics (p = 0.022). There were significantly more treatment changes recommended after walk-in eConsults than office visits (67 versus 44%, p < 0.0001). FTF visits were recommended more after office visits than walk-in clinics (46 versus 27%, p = 0.001). Overall, 21% (68/318) of patients ultimately attended FTF appointments. Discussion: SAF teledermatology improves diagnosis, reducing barriers to specialty care. Overall, potential FTF visit reduction was 79%. Expanding eConsult programmes, particularly in walk-in settings, and for use by NP/PAs or early career internists, may render dermatological care more expeditiously and avoid unnecessary FTF visits.

Pasquali et al (2020)Teledermatology and its Current Perspective43

Teledermatology is one of the most important and commonly employed subsets of telemedicine, a special alternative to face-to-face (FTF) doctorpatient consultation that refers to the use of electronic telecommunication tools to facilitate the provision of healthcare between the seeker and provider. It is used for consultation, education, second opinion, and monitoring medical conditions. This article will review basic concepts, the integration of noninvasive imaging technique images, artificial intelligence, and the current ethical and legal issues.

Peracca et al (2020) Implementing Teledermatology for Rural Veterans: An Evaluation Using the RE-AIM Framework44

Introduction: Few systematic evaluations of implementing teledermatology programs in large health care systems exist. We conducted a longitudinal evaluation of a U.S. Department of Veterans Affairs (VA)initiative to expand asynchronous consultative teledermatology services for rural veterans. Methods: The reach, effectiveness, adoption, implementation, and maintenance framework guided the evaluation, which included analysis of quantitative VA administrative data as well as an online survey completed by participating facilities. The first 2 years of the program were compared with the year before the start of funding. Results: Sixteen hub facilities expanded teledermatology’s reach over the 2- year period, increasing the number of referral spoke sites, unique patients served, and teledermatology encounters. Effectiveness was reflected as teledermatology constituted an increasing fraction of dermatology activity and served more remotely located patients. Adoption through defined stages of implementation progressed as facilities engaged in a variety of strategies to enhance teledermatology implementation, and facilitators and barriers were identified. Program maintenance was assessed by Program Sustainability Index scores, which reflected the importance of executive support, and ongoing concerns about staffing and longitudinal funding.

Discussion: Enabling hubs to create solutions that best fit their needs and culture likely increased reach and effectiveness. Important facilitators included organizational leadership and encouraging communication between stakeholders before and during the intervention. Conclusions:A systematic analysis of teledermatology implementation to serve rural sites in VA documented a high degree of implementation and sustainability as well as areas for improvement.

Rizvi et al (2020) Teledermatology in Norway using a mobile phone app45

Rashes, ulcers and skin lesions are well suited for telemedicine. We have developed a smartphone app, the first of its kind in Norway, where a referring physician can write a short medical history and take clinical and dermatoscopic photographs with a smartphone, which is then sent to and evaluated by a dermatologist. In the period from June 1st, 2017, to September 1st, 2019, clinical information and photographs of rash and skin lesions from 171 patients were sent by 40 primary care and nursing home physicians via the smartphone app to four dermatologists for diagnosis and therapeutic advice. A wide range of dermatological conditions were diagnosed, most commonly chronic ulcers (17%), eczema (15%) and pigmented lesions (13%). Assessed later by a dermatologist, referral for regular consultations with a specialist was avoided in 119 patients (70%). Sixteen patients (9%) were recommended a regular consultation with a dermatologist; information for prioritization in the specialist healthcare service was then provided. In 36 patients (21%), further measures by the referring physician were recommended. Our experience indicates that many ordinary consultations on rash, ulcers and skin lesions in the specialist healthcare services can be avoided when using the smartphone app.

Vestergaard et al (2020) Diagnostic accuracy and interobserver concordance: teledermoscopy of 600 suspicious skin lesions in Southern Denmark46

Background: Skin cancer incidences are increasing and early diagnosis, especially of malignant melanoma, is crucial. Teledermatology including teledermoscopy (TDS) can be used to triage referrals of suspicious skin lesions, however, this is not currently recommended in Denmark. Objectives: To evaluate diagnostic accuracy, sensitivity, specificity and interobserver concordance of TDS, and to evaluate the number of incidental lesions potentially missed by TDS. Methods: Fifty general practices were invited to send images of suspicious skin lesions for evaluation using smartphone TDS. Simultaneously, the patient was referred for a face-to-face (FTF) consultation. Images for TDS were independently evaluated by two dermatologists; a third dermatologist performed the FTF consultation. Diagnosis, management plan and level of diagnostic confidence were noted. For TDS photo quality was rated, and for FTF any incidental findings were described. Results: Six hundred lesions in 519 patients were included. The diagnostic accuracy was significantly higher on FTF evaluation than on TDS (P < 0.01). However, this was associated with a significant difference in specificity (P ≤ 0.012) whereas no significant difference was found in sensitivity. The concordance between FTF and TDS, and the interobserver concordance of two TDS evaluations was moderate to substantial (AC1 = 0.57-0.71). Incidental melanomas were found in 0.6% of patients on FTF evaluation, adding an extra 13% of melanomas. However, on TDS these patients’ photographed lesions all warranted FTF follow-up, where these melanomas would have been identified. Conclusion: In this large prospective study, no significant difference in sensitivity was observed between FTF and TDS, but specificity was lower on TDS than FTF. Taking management plans into account, we would, however, potentially have dismissed 2 of 23 melanomas, if only TDS had been used for assessment. One of these was a melanoma located on the scalp, an anatomic region less suitable for TDS.

Wang et al (2020) Clinical effectiveness and cost-effectiveness of teledermatology: Where are we now, and what are the barriers to adoption?47

There has been rapid growth in teledermatology over the past decade, and teledermatology services are increasingly being used to support patient care across a variety of care settings. Teledermatology has the potential to increase access to high-quality dermatologic care while maintaining clinical efficacy and cost-effectiveness. Recent expansions in telemedicine reimbursementfrom the Centers for Medicare and Medicaid Services (CMS) ensure that teledermatology will play an increasingly prominent role in patient care. Therefore, it is important that dermatologists be well informed of both the promises of teledermatology and the potential practice challenges a continuously evolving mode of care delivery brings. In this article, we will review the evidence on the clinical and cost-effectiveness of teledermatology and we will discuss system-level and practice-level barriers to successful teledermatology implementation as well as potential implications for dermatologists.

Young et al (2020)Artificial Intelligence in Dermatology: A Primer48

Artificial intelligence is becoming increasingly important in dermatology, with studies reporting accuracy matching or exceeding dermatologists for the diagnosis of skin lesions from clinical and dermoscopic images. However, real-world clinical validation is currently lacking. We review dermatological applications of deep learning, the leading artificial intelligence technology for image analysis, and discuss its current capabilities, potential failure modes, and challenges surrounding performance assessment and interpretability. We address the following three primary applications: 1.teledermatology, including triage for referral to dermatologists; 2. augmenting clinical assessment during face-to-face visits; and 3. dermatopathology. We discuss equity and ethical issues related to future clinical adoption and recommend specific standardization of metrics for reporting model performance.

Bridges et al (2019) Utility of Dermatology Extension for Community Healthcare Outcomes (ECHO) sessions in the adult and paediatric population49

Introduction: Primary care provider (PCP) competency in dermatology is inadequate despite the high volume of patients with skin conditions. Better education and access to dermatology expertise is vital to improve patient care. We present a comprehensive case-based evaluation of Dermatology Extension for Community Healthcare Outcomes (ECHO) sessions, an innovative videoconferencing educational model, by determining the diagnostic and treatment accuracy of dermatological conditions by PCPs over a 2-year period. Methods: This is a retrospective cross-sectional study evaluating the use and impact of Dermatology ECHO over a 2-year period. Outcomes assessed include patient demographics, PCPs’ diagnostic accuracy, and expert treatment impact. Results were analysed using summary statistics and Pearson’s chi-square test to describe the adult and paediatric populations.

Results: One hundred and sixty-seven adult cases and 56 paediatric cases were presented in 2016-2017. Among the 223 cases, 137 adult and 44 paediatric cases were complete and eligible for analysis. The mean lesion duration was 3.3 years in adults and 2.9 years in children prior to presentation. Upon case presentation, almost half (43.8%) of the adult cases were incorrectly diagnosed by their PCP with 18.8% receiving a partially correct diagnosis. PCPs had greater diagnostic accuracy in children (45% correct diagnosis, 27.5% partially correct, 27.5% incorrect). Expert treatment recommendations benefited 83.6% of adult cases and 72.5% of paediatric cases. Discussion: This study highlights the need for better dermatology access and teaching opportunities among PCPs in Missouri. Dermatology ECHO provides a platform for didactic learning and case presentations to improve dermatology competency among PCPs.

Cheung et al (2019) Pilot Teledermatology Service for Assessing Solitary Skin Lesions in a Tertiary London Dermatology Center50

Background: Efficient clinical pathways are needed to meet the growing pressures in dermatology due to the significant rise in the number of suspected skin cancer referrals. Our hospital serves a wide geographical area and receives a large number of 2-week-wait (2WW) suspected skin cancer referrals. In the United Kingdom, approximately 10-12% of 2WW referrals are diagnosed as skin cancers fulfilling the 2WW criteria. Purpose: We sought to assess the role of teledermatology in reducing hospital consultations for patients referred via the dermatology 2WW pathway. Methods: We piloted a teledermatology service and detailed the clinical outcomes of patients with solitary skin lesions of uncertain diagnosis triaged through this pathway. Seventy-six primary care referrals were reviewed by consultant dermatologists and analyzed against the British Association of Dermatologists’ teledermatology audit standards. Results: In 52/76 (68%) of patients, confident benign diagnoses were made, avoiding the need for a face-to-face (FTF) consultation. Conclusions: Our results showed that with adequate image quality, teledermatology can be used to accurately diagnose skin lesions. Implications: Teledermatology can significantly reduce the number of urgent referrals necessitating FTF appointments, therefore providing a new solution to streamline care delivery.

Coustasse et al (2019) Use of Teledermatology to Improve
Dermatological Access in Rural Areas51

Introduction:Dermatological access in rural regions has been impacted due to an acute, global dermatologist shortage coupled with a striking disparity in dermatologist density between urban and rural areas. As a result, the dermatological arena has been under notable pressure to amplify access. Teledermatology has entailed the use of technology to provide dermatological services to individuals located at a remote distance. The purpose of this literature review was to examine the effect of utilization of teledermatology to determine enhancement of dermatological access to residents of rural areas. Materials and Methods: This review followed a systematic approach and utilized five electronic databases to obtain peer-reviewed journal articles. A PRISMA approach was used and a total of 86 references were employed. Results: Teledermatology programs have been able to complement conventional dermatological care to enhance dermatological access to rural areas that have suffered from a shortage of dermatologists and could aid in supplementing traditional care as well. Within rural settings, the results of three studies in this review indicated the importance of improved quality for diagnostic precision, whereas one study reported that clinical images might not provide sufficient insight to deliver clear-cut diagnoses. In addition, enhancements in diagnostic precision could be obtained by upgrades in phone cameras to capture images. Finally, to most of the existing literature, in using teledermatology, physician satisfaction has been stronger than patient satisfaction.

Conclusions: Teledermatology has had a beneficial impact in improving dermatological access to rural areas. The success of this technology is contingent upon the commitment and willingness of the dermatologist in utilizing it.

Gamelas et al (2019) Positive Predictive Value of Melanoma Diagnosis in
Store-and-Forward Teledermatology52

Background:Although store-and-forward teledermatology (SFT) has demonstrated good diagnostic sensitivity for melanoma, little is known about the diagnostic precision (positive predictive value, PPV). Introduction:We conducted this investigation to ascertain the PPV of melanoma diagnosis among teledermatology readers. Materials and Methods:We reviewed teledermatology consultations on 8,706 patients completed during the period February 1, 2015-January 31, 2016. Melanoma was included in the differential diagnosis of 551 conditions. We conducted a chart review of each condition to determine the final diagnosis. Results:We ascertained a final diagnosis in 503 conditions. Sixty-nine conditions were ultimately diagnosed as melanoma, a PPV of 13.7%. There was considerable variability in PPV among readers. Image quality was associated with higher PPV.

Discussion:Overall, SFT program PPV compared favourably with that found in two published studies of face-to-face dermatology clinic care. Conclusion: To increase the diagnostic precision of SFT program melanoma diagnosis, efforts should be directed toward improving selected individual reader’s PPV and image quality.

Bianchi et al (2019)Dermatologists’ perceptions on the utility and limitations of teledermatology after examining 55,000 lesions53

Introduction: Few studies have assessed the perception of teledermatologists about the utility and limitations of teledermatology, especially to diagnose a broad range of skin diseases. This study aimed to evaluate dermatologists’ confidence in teledermatology, its utility and limitations for dermatological conditions in primary care. Methods: An analytical study that used a survey for dermatologists who diagnosed 30,916 patients with 55,012 lesions through teledermatology during a 1-year project in São Paulo, Brazil. Results: Dermatologists found teledermatology useful for triage and diagnosis, especially for xerotic eczema, pigmentary disorders and superficial infections. Their confidence in teledermatology was statistically higher by the end of the project (p = 0.0012). Limitations included some technical issues and the impossibility to suggest how soon the patient should be assisted face-to-face by a dermatologist. The most treatable group of diseases by teledermatology was superficial infections (92%). The use of dermoscopy images would significantly increase the confidence to treat atypical naevi and malign tumours (p < 0.0001 and p = 0.0003 respectively). Follow-ups by teledermatology or feedback from primarycare physicians would be desirable, according to the dermatologists. Discussion: We found it interesting that dermatologists became increasingly confident in teledermatology after the project and how they classified teledermatology as useful for triage, diagnosis and even treatment of most types of skin conditions followed at primary care. Dermoscopy should definitely be added to the photographs, especially for malignant tumours and atypical naevi. Most of the technical limitations found could be solved with a few improvements in the software/platform.

Ikoma et al (2019)Measurement of Nocturnal Scratching in Patients with Pruritus Using a Smartwatch: Initial Clinical Studies with the Itch Tracker App54

Three clinical studies were conducted to test a newly-developed app for smartwatches, which included an algorithm to measure nocturnal scratching using acceleration data. The first study in 5 patients with atopic dermatitis demonstrated high reliability ofthe app for measurement of scratching compared with video monitoring (positive predictive value 90.2 ± 6.6%, sensitivity 84.6 ± 10.2%, correlation of scratching duration per h r = 0.851-0.901, p < 0.001). The second study in 20 patients with atopic dermatitis and 10 healthy volunteers showed that total scratching duration in patients was significantly longer than in healthy volunteers and correlated positively with Eczema Area and Severity Index (EASI) scores. In the third study, conducted in an open-entry manner in which 201 evaluable participants measured nocturnal scratching, those who self-reported itch or pruritic diseases had a significantly longer duration of scratching than those who did not. In conclusion, this app has a high reliability and potential clinical usefulness for measurement of nocturnal scratching.

Koh et al (2019) Consumer Acceptance and Expectations of a Mobile Health Application to Photograph Skin Lesions for Early Detection of Melanoma55

Background: Mobile teledermoscopy may facilitate skin self-examinations (SSEs) and further improve monitoring and detection of melanoma. Objective: To assess consumer acceptability and expectations of a mobile health app used to: 1. instruct SSE; and 2. conduct consumer-performed mobile teledermoscopy. Methods: People aged 18 years and above were invited to participate in either an online survey or a focus group in Brisbane, Australia. Participants were asked about their SSE practices, mobile teledermoscopy acceptance, and app design and functionality. The online survey responses and focus group discussions were coded by two researchers who conducted thematic analysis. Results: Four focus groups were held with a total of 28 participants; 88 participants completed the online survey. The mean ages of participants in the focus group and online survey were 46 and 38 years, respectively. There were more males in the focus groups (61%, 17/28) compared to the online survey (19%, 17/88). Regular SSEs were conducted by 56 (64%) of the online survey participants. Barriers to SSE were forgetfulness (44%), low self-perceived risk of melanoma (25%) and low confidence in conducting SSEs (25%). The large majority of online survey participants (95%) would consider sending photos of their skin lesions to a medical practitioner via an app. Focus group participants reported that they would accept using mobile teledermoscopy; however, they would prefer to use it to monitor lesions between face-to-face consultations. Conclusions: Overall, participants had positive views on using mobile teledermoscopy to send images of skin lesions to a dermatologist or other medical practitioner.

Marwaha et al (2019) Comparative effectiveness study of face-to-face
and teledermatology workflows for diagnosing skin cancer56

Background: The effectiveness and value of teledermatology and face-to-face workflows for diagnosing lesions are not adequately understood. Objective:We compared the risks of biopsy and cancer diagnosis among 2 face-to-face workflows [direct referral and roving dermatologist] and 4 teledermatology workflows. Methods: Retrospective study of 59,279 primary care patients presenting with a lesion from January through June 2017. Results: One teledermatology workflow achieved high-resolution images with use of a dermatoscope-fitted digital camera, a picture archiving and communication system, and image retrieval to a large computer monitor in contrast to a smartphone screen. Compared with direct referral, this workflow was associated with a 9% greater probability of cancer detection (95% confidence interval [CI], 2%-16%), a 4% lower probability of biopsy (relative risk, 0.96; 95% CI, 0.93-0.99), and 39% fewer face-to-face visits (relative risk, 0.61; 95% CI, 0.57-0.65). Other workflows were less effective. Limitations: Differing proficiencies across teledermatology workflows and selection of patients for direct referral could have caused bias. Conclusion: Implementation is critical to the effectiveness of teledermatology.

Mehrtens et al (2019) A 14-year review of a UK teledermatology service:
experience of over 40 000 teleconsultations57

Background: There is a paucity of published evidence of established teledermatology (TD) services in the UK. An in-house TD service using store-and-forward technology was set up at a large regional dermatology department in 2004. Aim: To review the TD service at our centre, including teleconsultation numbers, coding of diagnoses and patient outcomes. Methods: Retrospective data were retrieved using the electronic patient database, from 31 July 2004 to 31 July 2018. More detailed information on patient outcomes was obtained from patient notes and histology records. A paper questionnaire was distributed to 100 patients to obtain patient feedback. Results: In total, 40 201 teleconsultations were made over 14 years, and 64% of cases were coded (n = 25 555), of which 77% were lesions. The most common coded lesions were benign naevus (25%), seborrhoeic keratosis (22%) and basal cell carcinoma (19%). Of the total number of cases, 50% were discharged to their general practitioner with advice, 34% were booked for surgery and 16% were booked for a face-to-face appointment. In the survey, 82% of patients surveyed felt that the service was ‘good’ or ‘very good’. A detailed study between 1 January 2015 and 1 January 2016 showed that there were 383 patients (10%) with no diagnosis made following teleconsultation, suggesting diagnostic uncertainty. Reasons for this included lack of diagnostic features, possibility of malignancy and service factors. Within this cohort, there was 68% diagnostic concordance. Conclusions: We have set up a successful TD service at a UK centre, which has prevented 16 282 face-to-face appointments over 14 years. Patient feedback has been very good. Review of cases with diagnostic uncertainty provides important information for service improvement and has not previously been documented.

Phillips et al (2019) Assessment of Accuracy of an Artificial Intelligence Algorithm to Detect Melanoma in Images of Skin Lesions58

Importance: A high proportion of suspicious pigmented skin lesions referred for investigation are benign. Techniques to improve the accuracy of melanoma diagnoses throughout the patient pathway are needed to reduce the pressure on secondary care and pathology services. Objective: To determine the accuracy of an artificial intelligence algorithm in identifying melanoma in dermoscopic images of lesions taken with smartphone and digital single-lens reflex (DSLR) cameras. Design, Setting, and Participants: This prospective, multicenter, single-arm, masked diagnostic trial took place in dermatology and plastic surgery clinics in 7 UK hospitals. Dermoscopic images of suspicious and control skin lesions from 514 patients with at least 1 suspicious pigmented skin lesion scheduled for biopsy were captured on 3 different cameras. Data were collected from January 2017 to July 2018. Clinicians and the Deep Ensemble for Recognition of Malignancy, a deterministic artificial intelligence algorithm trained to identify melanoma in dermoscopic images of pigmented skin lesions using deep learning techniques, assessed the likelihood of melanoma. Initial data analysis was conducted in September 2018; further analysis was conducted from February 2019 to August 2019. Interventions: Clinician and algorithmic assessment of melanoma. Main Outcomes and Measures: Area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity of the algorithmic and specialist assessment, determined using histopathology diagnosis as the criterion standard.

Results: The study population of 514 patients included 279 women (55.7%) and 484 white patients (96.8%), with a mean (SD) age of 52.1 (18.6) years. A total of 1550 images of skin lesions were included in the analysis (551 [35.6%] biopsied lesions; 999 [64.4%] control lesions); 286 images (18.6%) were used to train the algorithm, and a further 849 (54.8%)images were missing or unsuitable for analysis. Of the biopsied lesions that were assessed by the algorithm and specialists, 125 (22.7%) were diagnosed as melanoma. Of these, 77 (16.7%) were used for the primary analysis. The algorithm achieved an AUROC of 90.1% (95% CI, 86.3%-94.0%)for biopsied lesions and 95.8% (95% CI, 94.1%-97.6%)for all lesions using iPhone 6s images; an AUROC of 85.8% (95% CI, 81.0%-90.7%)for biopsied lesions and 93.8% (95% CI, 91.4%-96.2%)for all lesions using Galaxy S6 images; and an AUROC of 86.9% (95% CI, 80.8%-93.0%)for biopsied lesions and 91.8% (95% CI, 87.5%-96.1%)for all lesions using DSLR camera images. At 100% sensitivity, the algorithm achieved a specificity of 64.8% with iPhone 6s images. Specialists achieved an AUROC of 77.8% (95% CI, 72.5%-81.9%) and a specificity of 69.9%.

Conclusions and Relevance: In this study, the algorithm demonstrated an ability to identify melanoma from dermoscopic images of selected lesions with an accuracy similar to that of specialists.

Schnitzler et al (2019)Validation of ‘ItchApp©’ in Poland and in the USA: multicentre validation study of an electronical diary for the assessment of pruritus59

Background: Although chronic pruritus affects a large part of the population, its reliable assessment remains difficult. Electronical diaries are often used in multicentre clinical trials. The ItchApp© for Android was developed to assess itch intensity and course and was validated for the German language in 2017. Objective: To validate ItchApp© for the use in the Polish and US English languages. Methods: Fifty-three subjects in Poland and thirty subjects in the USA with chronic pruritus completed the paper-based and app-based questionnaires. These questionnaires contained items for measuring the itch intensity, including a numerical rating scale (NRS) and verbal rating scale (VRS), and for detecting the change of pruritus since the beginning of treatment. Results: The ItchApp© showed a high level of test-retest reliability [Intraclass correlation, Kappa and Kendall-Tau B coefficients: 0.915-1.000 (Poland) and 0.863-1.000 (USA)]. The convergent validity showed strong correlation between the itch intensity scales on the ItchApp© (Items II-IV = VRS mean, NRS mean and NRS worst) and the paper-based itch intensity scales (mean and worst: VRS, NRS, VAS)[Spearman-Rho and Pearson correlation coefficients: 0.710-0.987 (Poland) and 0.646-0.954 (USA)]. The ItchApp© items moderately correlated with the ItchyQol scores [SpearmanRho and Pearson correlation coefficients: 0.303-0.554 (Poland) and 0.275- 0.447 (USA)]. After completing the ItchApp© questionnaire, a feasibility questionnaire was completed and showed that subjects feel the app is well suited for assessing pruritus. Conclusion: We provide evidence for the ItchApp© as a validated eDiary for the assessment of pruritus in Polish and US English languages, enabling its use in multicentre international clinical trials.

Seite et al (2019)Development and accuracy of an artificial intelligence algorithm for acne grading from smartphone photographs60

We developed an artificial intelligence algorithm (AIA)for smartphones to determine the severity of facial acne using the GEA scale and to identify different types of acne lesion [comedonal, inflammatory] and postinflammatory hyperpigmentation (PIHP) or residual hyperpigmentation. Overall, 5972 images obtained with smartphones from 1072 acne patients were collected. Three trained dermatologists assessed the acne severity for each patient. One acne severity grade per patient grade given by the majority of the three dermatologists from the two sets of three images was used to train the algorithm. Acne lesion identification was performed from a subgroup of 348 images using a tagging tool; tagged images served to train the algorithm. The algorithm evolved and was adjusted for sensibility, specificity and correlation using new images. The correlation between the GEA grade and the quantification and qualification of acne lesions both by the AIA and the experts for each image were evaluated for all AIA versions. At final version 6, the GEA grading provided by AIA reached 68% and was similar to that provided by the dermatologists. Between version 4 and version 6, AIA improved precision results multiplied by 1.5 for inflammatory lesions, 2.5 for non-inflammatory lesions and by 2 for PIHP; recall was improved by 2.6, 1.6 and 2.7. The weighted average of precision and recall or F1 score was 84% for inflammatory lesions, 61% for noninflammatory lesions and 72% for PIHP.

Singh and Gupta (2019)Recent advancement in the early detection of melanoma using computerized tools: An image analysis perspectiv61

Background: The paper reviews the advancement of tools and current technologies for the detection of melanoma. We discussed several computational strategies from pre- to postprocessing image operations, descriptors, and popular classifiers to diagnose a suspected skin lesion based on its virtual similarity to the malignant lesion with known histopathology. We reviewed the current state of smart phone-based apps as diagnostic tools for screening. Methods: A literature survey was conducted using a combination of keywords in the bibliographic databases: PubMed, AJCC, PH2, EDRA, and ISIC melanoma project. A number of melanoma detection apps were downloaded for two major mobile operating systems, iOS and Android; their important uses, key challenges, and various expert opinions were evaluated and also discussed. Results: We have provided an overview of research on the computer-aided diagnosis methods to estimate melanoma risk and early screening. Dermoscopic images are the most viable option for the advent of new image processing technologies based on which many of the skin cancer detection apps are being developed recently. We have categorized and explored their potential uses, evaluation criteria, limitations, and other details. Conclusion: Such advancements are helpful in the sense they are raising awareness. Diagnostic accuracy is the major issue of smart phone-based apps and it cannot replace an adequate clinical experience and biopsy procedures.

Von Wangenheim and Nunes (2019) Creating a Web Infrastructure for the Support of Clinical Protocols and Clinical Management: An Example in Teledermatology 62

Introduction:We describe a teledermatology infrastructure, implemented as part of a statewide large-scale telemedicine network, designed to provide comprehensive support for examination and clinical management protocols, which includes telediagnostic and patient triage and referral. It was implemented as a web-based system and an associated mobile application that supports both the primary healthcare facility team and the specialist during the patient care process. Methods:We describe the process models, protocols and technology employed, and the requirements generated for their development. We also present the results and experiences gained in implementing the model. The teledermatology service was implemented in 313 primary healthcare facilities in 286 municipalities in the State of Santa Catarina, Brazil. This study covers the period from January 2014 to June, 2018. Results:During this period, the teledermatology infrastructure processed 83,100 teledermatology examinations, of which 75,832 were validated and employed for patient triage and clinical management. Teledermatology allowed 33,112 patients to avoid further referral and be treated locally. Of this cohort, 7,513 patients presented more complex dermatoses that could be treated at the primary care level using telehealth-supported clinical management. Conclusions: Results indicate that this model contributes not only to the resolution of cases at the primary care level but also to the progressive improvement of the technical quality of dermatological examinations performed by technical staff at the primary healthcare.

Abbott et al (2018) Smartphone use in dermatology for clinical
photography and consultation: Current practice and the law63

Background: Smartphones are rapidly changing the way doctors capture and communicate clinical information, particularly in highly visual specialties such as dermatology. An understanding of how and why smartphones are currently used in clinical practice is critical in order to evaluate professional and legal risks, and to formulate policies that enable safe use of mobile technologies for the maximal benefit of practitioners and patients. Methods: Australian dermatologists and dermatology trainees were surveyed on their current practices relating to clinical smartphone use. Results:Of the 105 respondents, 101 provided useable results. The data show clinical smartphone use is common and frequent, with more than 50% of respondents sending and receiving images on their smartphones at least weekly. Clinical photographs were usually sent via multimedia message or email and were commonly stored on smartphones (46%). Security measures adopted to protect data were limited. There was inadequate documentation of consent for transmission of photographs and advice provided. Only 22% of respondents were aware of clear policies in their workplace regarding smartphone use, and a majority desired further education on digital image management. Conclusions: In respect ofthe frequency of use and the degree of importance placed on the ability to send and receive clinical images, clinical smartphone use will persist and will likely increase over time. Current practices are insufficient to comply with professional and legal obligations, and increase practitioners’ vulnerability to civil and disciplinary proceedings. Further education, realistic policies and adequate software resources are critical to ensure protection of patients, practitioners and the reputation of the dermatological profession.

Barcaui and Lima (2019) Application of Teledermoscopy in the Diagnosis of Pigmented Lesions64

Background: Dermatology, due to the peculiar characteristic of visual diagnosis, is suitable for the application of modern telemedicine techniques, such as mobile teledermoscopy. Objectives: To evaluate the feasibility and reliability of the technique for the diagnosis of pigmented lesions. Methods: Through the storage and routing method, 41 pigmented lesions were analyzed. After the selection of the lesions during the outpatient visit, the clinical and dermatoscopic images were obtained by the resident physician through the cellphone camera and sent to the assistant dermatologist by means of an application for exchange of messages between mobile platforms. Firstly, the assistant dermatologist described the visualized dermatoscopic structures and defined its diagnosis and conduct, based solely on the evaluation of the clinical and dermatoscopic images, without having the knowledge of the anamnesis data. Afterwards, the same assistant dermatologist evaluated the patient face to face, defining the dermatoscopic structures, diagnosis, and conduct. The data obtained through teledermoscopy and face-to-face assessments were compared and accuracy was defined as the concordance between the diagnoses. Results: A match rate of 90% between teledermoscopic and face-to-face diagnosis was demonstrated; McNemar’s statistical analysis, whose p value was 0.1366, showed no evidence to support the inferiority of the teledermoscopic method.

Brinker et al (2015) Teledermatology: Comparison of Store-and-Forward Versus Live Interactive Video Conferencing65

A decreasing number of dermatologists and an increasing number of patients in Western countries have led to a relative lack of clinicians providing expert dermatologic care. This, in turn, has prolonged wait times for patients to be examined, putting them at risk. Store-and-forward teledermatology improves patient access to dermatologists through asynchronous consultations, reducing wait times to obtain a consultation. However, live video conferencing as a synchronous service is also frequently used by practitioners because it allows immediate interaction between patient and physician. This raises the question of which of the two approaches is superior in terms of quality of care and convenience. There are pros and cons for each in terms of technical requirements and features. This viewpoint compares the two techniques based on a literature review and a clinical perspective to help dermatologists assess the value of teledermatology and determine which techniques would be valuable in their practice.

Dahlen Gyllencreutz et al (2018) Teledermoscopy images acquired in primary health care and hospital settings – a comparative study of image quality66

Background: The incidence of melanoma and non-melanoma skin cancer is increasing, which has also lead to an increase in referrals between primary health care (PHC) and dermatology departments, putting a strain on healthcare services. Teledermoscopy (TDS) referrals from PHC can improve the triage process for patients with suspicious skin tumours, but the quality of the images included could potentially affect its usefulness. Objective: To critically appraise the quality of the dermoscopic images of a smartphone TDS system, by comparing the TDS referral images with images of the same tumours acquired at the department of dermatology. Methods: Two dermatologists rated the image quality of two image sets from 172 skin tumours separately. The dermatologists also decided on a main diagnosis, differential diagnoses and described the visible dermoscopic structures. Results: The images acquired in PHC were rated as having slightly lower quality, but there was no significant difference. PHC images and dermatology images were of intermediate-to-high quality in 95.5%-97.7% and 96.5%- 98.8%, respectively. There was no difference in agreement between the TDS diagnosis based on the two image sets with the final clinical or histopathological diagnosis. Most image pairs (81.4% and 83.7%) received the same main diagnosis by the two evaluators. When this was not the case, the most common reasons were poor focus, excessive pressure applied when acquiring the image or inadequate amount of zoom. Conclusion: TDS performed in PHC with a smartphone-based system does not seem to negatively affect the usefulness of TDS referrals. Thus, physicians at PHC do not necessarily need to be trained photographers to ensure adequate TDS image quality. Knowledge about technical difficulties could however be used when training PHC staff, to improve the image quality further.

Lee and English (2018) Teledermatology: A Review and Update67

Telemedicine is slowly transforming the way in which healthcare is delivered and has the potential to improve access to subspecialty expertise, reduce healthcare costs, and improve the overall quality of care. While many subspecialty fields within medicine today have either experimented with or begun to implement telemedicine platforms to enable remote consultation and care, dermatology is particularly suited for this care system as skin disorders are uniquely visible to the human eye. Through teledermatology, diagnostic images of skin disorders with accompanying clinical histories can be remotely reviewed by teledermatologists by any number of modalities, such as photographic clinical images or live video teleconferencing. Diagnoses and treatment recommendations can then be rendered and implemented remotely. The evidence to date supports both its diagnostic and treatment accuracy and its cost effectiveness. Administrative, regulatory, privacy, and reimbursement policies surrounding this dynamic field continue to evolve. In this review, we examine the history, evidence, and administrative landscape surrounding teledermatology and discuss current practice guidelines and ongoing controversies.

Singer et al (2018) Using Network Oriented Research Assistant (NORA) Technology to Compare Digital Photographic With In-Person Assessment of Acne Vulgaris68

Importance: Teledermatology has undergone exponential growth in the past 2 decades. Many technological innovations are becoming available without necessarily undergoing validation studies for specific dermatologic applications. Objective: To determine whether patient-taken photographs of acne using Network Oriented Research Assistant (NORA) result in similar lesion counts and Investigator’s Global Assessment (IGA)findings compared with inperson examination findings. Design, Setting, and Participants: This pilot reliability study enrolled consecutive patients with acne vulgaris from a single general dermatology practice in Los Angeles, California, who were able to use NORA on an iPhone 6 to take self-photographs. Patients were enrolled from January 1 through March 31, 2016. Each individual underwent in-person and digital evaluation of his or her acne by the same dermatologist. A period of at least 1 week separated the in-person and digital assessments of acne. Interventions: All participants were trained on how to use NORA on the iPhone 6 and take photographs of their face with the rear-facing camera. Main outcomes and measures: Reliability of patient-taken photographs with NORA for acne evaluation compared with in-person examination findings. Acne assessment measures included lesion count [total, inflammatory, noninflammatory, and cystic] and IGA for acne severity. Results: A total of 69 patients (37 male [54%] and 32 female [46%]; mean [SD] age, 22.7 [7.7] years) enrolled in the study. The intraclass correlation coefficients of in-person and photograph-based acne evaluations indicated strong agreement. The intraclass correlation coefficient for total lesion count was 0.81; for the IGA, 0.75. Inflammatory lesion count, noninflammatory lesion count, and cyst count had intraclass correlation coefficients of 0.72, 0.72, and 0.82, respectively. Conclusions and Relevance: This study found agreement between acne evaluations performed in person and from self-photographs with NORA. As a reliable telehealth technology for acne, NORA can be used as a teledermatology platform for dermatology research and can increase access to dermatologic care.

Trettel et al (2018) Telemedicine in dermatology: findings and
experiences worldwide -a systematic literature review69

Telemedicine has become an important element of health care in many countries and profited from the technological progress of the last two decades. Due to the visual character of the dermatological specialty, teledermatology in particular participated in that development and is becoming a major tool in dermatological consultation. The objective of this article was to identify the use of teledermatology across the world based on published original articles. A systematic literature search of the MEDLINE and Embase databases for eligible publications with predefined inclusion and exclusion criteria, and a cross-validation search were conducted. Search results were reviewed systematically. The search resulted in 204 publications meeting the inclusion criteria for analysis. The highest number of published studies on teledermatology was performed in theUnited States, followed by the United Kingdom, Spain, the Netherlands, Italy and Austria. The majority of dermatological indications for telemedical consultations were not specified or included various kinds of skin diseases, followed by skin cancer and wounds. Research questions predominantly focused on concordance, effectiveness and cost-effectiveness to determine the value. Teledermatology proved to be a reliable consultation tool in the majority of studies. If specified, telemedicine was used in daily dermatological routine for patient management purposes, to consult patients in peripheral locations, or for medical support in nursing homes or home care settings. The application of teledermatology worldwide is highest in North American and European countries, while countries with poor geographical distribution of physicians seem to be under-represented in teledermatological use, as concluded from publication output. Regarding indications, comparison with classic consultation and area of application, most studies were of general nature. For precise determination of the value, systematic studies would be needed. However, teledermatology is already accepted as a valid tool.

Walter et al (2018) A Teledermatology Scale-Up Framework and Roadmap for Sustainable Scaling: Evidence-Based Development70

Background: The objectives of South Africa’s electronic health strategy recognize the value proposition that telemedicine practices hold for rural and urban referrals, but a lack of accepted and formalized scale-up has impeded realization of benefits. While both synchronous and asynchronous teledermatology exist, these remain localized and not scaled-up. Skin pathology is often the first sign of an HIV/AIDS infection, which remains a major cause of morbidity and mortality in South Africa. It is essential to replace the current inefficient dermatology referral process with a swift, organized, and efficacious one. Objective: The objective of this study is to present an evidenced-based teledermatology scale-up framework (TDSF) and implementation roadmap (TDSF-IR).

Methods: A qualitative method with a design science research process model was used which consisted of 5 phases: 1. awareness, which confirmed the need for an evidence-based TDSF and supporting TDSF-IR; 2. suggestion, where a proposal was delivered on how to develop a TDSF and TDSF-IR; 3. development, where we identified recommended design requirements and used these to identify and critique existing teledermatology or related scaleup frameworks; 4. evaluation and validation, where we assessed outputs of the development phase against the design requirements and validated by confirming the veracity of the TDSF and TDSF-IR [validation involved 4 key senior teledermatology stakeholders using a questionnaire with a 5-point Likert scale]; and 5. conclusion, where validation results were used to finalize and communicate the TDSF and TDSF-IR to users.

Results: The study identified 5 TDSF components: eHealth building blocks, eHealth strategic objectives and budget, scale-up continuum periods, scaleup drivers, and scale-up phases. In addition, 36 subcomponents were identified. Each was further characterized and described to enable design of the final evidence-based TDSF. An implementation roadmap (TDSF-IR) was also prepared as a guide for an implementer with step-by-step instructions for application of the TDSF. For the validation study of the TDSF and supporting TDSF-IR, 4 purposively selected key senior teledermatology management stakeholders were asked if they found it useful as a guide to assist the South African public health system with teledermatology scaleup. The mean (SD) of Likert-scale rating was 4.0 (0.53) where 4=Agree and 33 of 36 responses were either agree or strongly agree.

Conclusions: This study developed a TDSF and supporting roadmap (TDSFIR)that are evidence-based. The proposed approach and described tools could be adapted to assist with ensuring scale-up and sustainability for other eHealth practices in other locations.

Altieri et al (2017) Interobserver reliability of teledermatology across all Fitzpatrick skin types71

Introduction:Demand for dermatologic services in safety net hospitals, which disproportionately serve patients with darker coloured skin, is growing. Teledermatology has the potential to increase access and improve outcomes, but studies have yet to demonstrate the reliability of teledermatology for all Fitzpatrick skin types. Methods:We assessed the reliability of teledermatologists’ diagnoses and management recommendations for store-and-forward teledermatology in patients with lightly pigmented (Fitzpatrick skin types I-III) versus darkly pigmented (Fitzpatrick skin types IV-VI) skin, when compared to in-person diagnosis and management decisions. This prospective study enrolled 232 adult patients, presenting with new, visible skin complaints in a Los Angeles county dermatology clinic. Forty-seven percent of patients were Fitzpatrick skin types I-III, and 53% were Fitzpatrick skin types IV-VI. Results: Percent concordance for the identical primary diagnosis was 53.2% in lighter (Fitzpatrick I-III) skin types and 56.0% in darker (Fitzpatrick IV-VI) skin types. There was no statistically significant difference in concordance rates between lighter and darker skin types for primary diagnosis. Concordance rates for diagnostic testing, clinic-based therapy, and treatments were similar in both groups of Fitzpatrick skin types. Discussion: These results suggest that teledermatology is reliable for the diagnosis and management of patients with all Fitzpatrick skin types.

Ariens et al (2017) Barriers and Facilitators to eHealth Use in Daily Practice: Perspectives of Patients and Professionals in Dermatology72

Background: The number of eHealth interventions in the management of chronic diseases such as atopic dermatitis (AD)is growing. Despite promising results, the implementation and use of these interventions is limited. Objectives: This study aimed to assess opinions of the most important stakeholders influencing the implementation and use of eHealth services in daily dermatology practice. Methods: The perspectives of health care professionals and patients towards the implementation and use of eHealth services in daily practice were assessed by using a mixed method design. A cross-sectional survey based on the eHealth implementation toolkit (eHit) was conducted to explore factors influencing the adoption of eHealth interventions offering the possibility of e-consultations, Web-based monitoring, and Web-based selfmanagement training among dermatologists and dermatology nurses. The perspectives of patients with atopic dermatitis (AD) regarding the use of eHealth services were discussed in an online focus group. Results: Health care professionals (n=99) and patients (n=9) acknowledged the value of eHealth services and were willing to use these digital tools in daily dermatology practice. Key identified barriers statements with <50% of the participants scoring totally agree or agree in the implementation and adoption of eHealth interventions included concerns about the availability (12/99, 12%) and allocation (14/99, 14%) of resources, financial aspects (26/99, 26%), reliability, security, and confidentially of the intervention itself (29/99, 29%), and the lack of education and training (6/99, 6%). Conclusions: Health care professionals and patients acknowledge the benefits arising from the implementation and use of eHealth services in daily dermatology practice. However, some important barriers were identified that might be useful in addressing the implementation strategy in order to enhance the implementation success of eHealth interventions in dermatology.

Boissin et al (2017) Image-based teleconsultation using smartphones or tablets: qualitative assessment of medical experts73

Background: Mobile health has promising potential in improving healthcare delivery by facilitating access to expert advice. Enabling experts to review images on their smartphone or tablet may save valuable time. This study aims at assessing whether images viewed by medical specialists on handheld devices such as smartphones and tablets are perceived to be of comparable quality as when viewed on a computer screen. Methods: This was a prospective study comparing the perceived quality of 18 images on three different display devices smartphone, tablet and computer by 27 participants (4 burn surgeons and 23 emergency medicine specialists). The images, presented in random order, covered clinical dermatological conditions, burns, electrocardiographs and X-rays and non-clinical subjects and their perceived quality was assessed using a 7- point Likert scale. Differences in devices’ quality ratings were analysed using linear regression models for clustered data adjusting for image type and participants’ characteristics: age, gender and medical specialty. Results: Overall, the images were rated good or very good in most instances and more so for the smartphone (83.1%, mean score 5.7) and tablet (78.2%, mean 5.5)than for a standard computer (70.6%, mean 5.2). Both handheld devices had significantly higher ratings than the computer screen, even after controlling for image type and participants’ characteristics. Nearly all experts expressed that they would be comfortable using smartphones (n=25) or tablets (n=26)for image-based teleconsultation. Conclusion: This study suggests that handheld devices could be a substitute for computer screens for teleconsultation by physicians working in emergency settings.

Chao et al (2017) Smartphone-Based Applications for Skin Monitoring and Melanoma Detection74

With the advancement of mobile technologies, smartphone applications have become widely available and gained increasing attention as a novel tool to deliver dermatologic care. This article presents a review of various apps for skin monitoring and melanoma detection and a discussion of current limitations in the field of dermatology. Concerns regarding quality, transparency, and reliability have emerged because there are currently no established quality standards or regulatory oversight of mobile medical apps. Only a few apps have been evaluated clinically. Further research is needed to evaluate the utility and efficacy of smartphone apps in skin cancer screening and early melanoma detection.

Creighton-Smith et al (2017)Incidence of melanoma and keratinocytic carcinomas in patients evaluated by store-and-forward teledermatology vs. dermatology clinic75

Background: It is unclear whether incidence of detected skin cancer in patients evaluated by store-and-forward teledermatology (SAF) vs. face-toface consultation (F2F) significantly differs, and whether such differences are because of variations in patient demographics, diagnostic accuracy, or both. Methods: This retrospective cohort study compares patient skin cancer risk profile, pre-post biopsy diagnostic accuracy, and detection rates of any skin cancer, melanoma, and keratinocytic carcinoma between all SAF teledermatology patients and a subset of randomly selected F2F consultations at VA-Boston Healthcare System in 2014. Results: Patients in the teledermatology (n = 434) and F2F visit cohorts (n = 587) had similar baseline demographics except a higher proportion of F2F patients had prior history of skin cancer, 22% (131/587) vs. 10% (45/434), P <0.001, and received biopsies, 27.2% (160/587) vs. 11.5% (50/434), P < 0.001. When adjusted for age, immunosuppression, and personal and family history of skin cancer, there were no significant differences between the two cohorts in detection rates for any skin cancer (9.5% vs. 5.8%, P = 0.3), melanoma (0.6% vs. 0%, P = N/A), or keratinocytic carcinoma (8.5% vs. 5.5%, P = 0.7). The two cohorts also had similar pre-post biopsy perfect diagnostic concordance, time from initial consult request to biopsy (45.5 d vs. 47.3 d, P = 0.8), and time from biopsy to definitive treatment (67.5 d vs. 65.4 d, P = 0.8). Conclusion: F2F patients were more likely to have prior history of skin cancer and receive biopsies. When adjusted for presence of skin cancer risk factors, incidence of detected melanoma, keratinocytic carcinoma, and any skin cancer was similar between SAF teledermatology and F2F patients.

Dahlen Gyllencreutz et al (2018)Diagnostic agreement and interobserver concordance with teledermoscopy referrals76

Background: Malignant melanoma and non-melanoma skin cancers are among the fastest increasing malignancies in many countries. With the help of new tools, such as teledermoscopy referrals between primary health care and dermatology clinics, the management of these patients could be made more efficient. Objective: To evaluate the diagnostic agreement and interobserver concordance achieved when assessing referrals sent through a mobile teledermoscopic referral system as compared to referrals sent via the current paper-based system without images. Methods: The referral information from 80 teledermoscopy referrals and 77 paper referrals were evaluated by six Swedish dermatologists. They were asked to answer questions about the probable diagnosis, the priority, and a management decision. Results: Teledermoscopy generally resulted in higher diagnostic agreement, better triaging and more malignant tumours being booked directly to surgery. The largest difference between the referral methods was seen for invasive melanomas. Referrals for benign lesions were significantly more often correctly resent to primary health care with teledermoscopy. However, referrals for cases of melanoma in situ were also incorrectly resent five times. The interobserver concordance was moderate with both methods. Conclusion: By adding clinical and dermoscopic images to referrals, the triage process for both benign and dangerous skin tumours can be improved. With teledermoscopy, patients with melanoma especially can receive treatment more swiftly.

Dugonik et al (2017) e-Derma -a Novel Wireless Dermatoscopy System77

Cutaneous Melanoma (CM)is a malignant tumour, and is one of the most rapidly growing cancers. Discovering a melanoma in the early stages of the disease is extremely difficult and, as such, only an invasive disease stage can be identified easily with the naked eye. Dermatoscopy is a diagnostic method intended to maximise early detection of CM performed by the dermatoscopy system. To address the limitations of existing systems a novel, wireless digital dermatoscopy system is presented for providing high-resolution images. It integrates a wire-free camera operation and offers a safe transfer of captured images to the computer. The working process of available dermatoscopy systems was studied, which are the most commonly used in everyday dermatology practice. Some findings such as operability, image quality, scalability, user-friendliness, and safeness were used for the development of an e-Derma dermatoscopy system. An assessment method was performed by a group of dermatoscopy trained dermatologists to evaluate the quality of the testing images. Finally, a laboratory evaluation of images in regard to different parameters such as sharpness, colour representation and illumination was performed with the side-by-side comparison of images of available dermatoscopy systems. e-Derma is a novel dermatoscopy system, which eliminates some limitations of existing systems and provides high-quality images. A novel low-budget highly capable dermatoscopy system is presented. The integrated wireless image transfer technology eliminates the movement limitations of a therapist. The image resolution is not limited by the integrated camera; it is easily upgradable with a wide range of on market alternative or improved camera models.

Finnane et al (2017) Proposed Technical Guidelines for the Acquisition of Clinical Images of Skin-Related Conditions78

Importance: Standardizing dermatological imaging is important to improve monitoring of skin lesions and skin conditions, ensure the availability of high-quality images for teledermatology, and contribute to the development of a robust archive of skin images to be used for research. Objective: To provide guidelines for the clinical application of the Standards for Dermatological Imaging set forward by the ISIC. Evidence Review: The ISIC recommendations were developed through a hybrid Delphi methodology. The methods for achieving consensus have been described previously. The practical application of these recommendations was evaluated by 2 clinical photographers with expertise in skin imaging. Images corresponding to each recommendation were taken by a clinical photographer and provided as visual examples of how these recommendations can be implemented in clinical practice. Results: The Standards for Dermatological Imaging developed by the ISIC members could be followed in the clinical setting. Images showing appropriate lighting, background color, field of view, image orientation, focus and depth of field, resolution, and scale and color calibration were obtained by the clinical photographer, by following the detailed recommendations for regional, close-up and dermoscopic images. Conclusions and Relevance: Adhering to the recommendations is both feasible and achievable in practice. Adopting these Standards is the first step in achieving international standardization of skin imaging, with the potential to improve clinical outcomes and research activities.

Foolad et al (2017) International inter-rater agreement in scoring acne severity utilizing cloud-based image sharing of mobile phone photographs79

Background: Cloud-based image sharing technology allows facilitated sharing of images. Cloud-based image sharing technology has not been well-studied for acne assessments or treatment preferences, among international evaluators. We evaluated inter-rater variability of acne grading and treatment recommendations among an international group of dermatologists that assessed photographs. Methods: This is a prospective, single visit photographic study to assess inter-rater agreement of acne photographs shared through an integrated mobile device, cloud-based, and HIPAA-compliant platform. Inter-rater agreements for global acne assessment and acne lesion counts were evaluated by the Kendall’s coefficient of concordance while correlations between treatment recommendations and acne severity were calculated by Spearman’s rank correlation coefficient. Results: There was good agreement for the evaluation of inflammatory lesions (KCC = 0.62, P < 0.0001), noninflammatory lesions (KCC = 0.62, P < 0.0001), and the global acne grading system score (KCC = 0.69, P < 0.0001). Topical retinoid, oral antibiotic, and isotretinoin treatment preferences correlated with photographic based acne severity. Conclusions: Our study supports the use of mobile phone based photography and cloud-based image sharing for acne assessment. Cloudbased sharing may facilitate acne care and research among international collaborators.

Grey et al (2017) Utility of Store and Forward Teledermatology for Skin Patch Test Readings80

Background: Teledermatology (TD)is the use of imaging technology to provide dermatology services at a distance. To date, studies assessing its application for grading skin patch test reactions have been lacking. Objectives: The aim was to compare conventional, in-person (IP) grading of skin patch test reactions with store-forward TD. Methods: Patients undergoing patch testing to the North American Contact Dermatitis Group (NACDG) screening series were invited to participate in this repeated-measures study. Photographs of the NACDG screening series patch sites were obtained at 2 time points: 48-hour and final readings. Teledermatology assessments were completed by the same staff dermatologist who performed the IP readings; 48-hour and final TD photographs were viewed at weeks 4 and 8 after the IP encounter, respectively, to prevent recall bias. Staff dermatologists were blinded to IP grading results. The main outcome was percent agreement. Eight categories of agreement were created according to possible pairings of TD and IP reading results. Three final outcome groups of success, indeterminate and failure were defined based on clinical significance. Results: One hundred one participants completed the study. There were 7070 comparison points between IP and TD final readings. Excluding negative/negative agreement, there was success of TD in 54% of final readings. Indeterminate agreement with possible clinical significance was present in 40% of final readings. There was failure [definite clinical significance]in 6% of final readings.

Conclusions: Teledermatology may be a viable option for grading skin patch test reactions, particularly for clinicians who perform limited patch testing. However, a clinically significant “failure” rate of 6% and practical barriers to TD implementation may preclude its widespread use for skin patch testing in tertiary referral centers where large numbers of patches are tested per patient.

Marchell et al (2017) Comparing High Definition Live Interactive and Store-and-Forward Consultations to In-Person Examinations81

Background: There is little teledermatology research directly comparing remote methods, even less research with two in-person dermatologist agreement providing a baseline for comparing remote methods, and no research using high definition video as a live interactive method. Objective: To compare in-person consultations with store-and-forward and live interactive methods, the latter having two levels of image quality. Methods: A controlled study was conducted where patients were examined in-person, by high definition video, and by store-and-forward methods. The order patients experienced methods and residents assigned methods rotated, although an attending always saw patients in-person. The type of high definition video employed, lower resolution compressed or higher resolution uncompressed, was alternated between clinics. Primary and differential diagnoses, biopsy recommendations, and diagnostic and biopsy confidence ratings were recorded. Results: Concordance and confidence were significantly better for in-person versus remote methods and biopsy recommendations were lower. Store-and-forward and higher resolution uncompressed video results were similar and better than those for lower resolution compressed video. Limitations: Dermatology residents took store-and-forward photos and their quality was likely superior to those normally taken in practice. There were variations in expertise between the attending and second and third year residents. Conclusion: The superiority of in-person consultations suggests the tendencies to order more biopsies or still see patients in-person are often justified in teledermatology and that high resolution uncompressed video can close the resolution gap between store-and-forward and live interactive methods.

Marchell et al (2017) Patient and Provider Satisfaction with Teledermatology82

Background: There is little research comparing dermatologist and patient satisfaction with in-person, store-and-forward, and live interactive examinations. Objective: To compare satisfaction with in-person examinations to storeand-forward and live interactive consultations having two types of video. Methods: A controlled study was conducted where patients referred for dermatology consultations were examined in-person, by video, and by store-and-forward methods. Video changed between compressed and uncompressed on alternate clinics. Patients and dermatologists rated encounters after each examination. Dermatologists doing store-and-forward evaluations rated the quality of information provided. After experiencing all methods patients ranked their preferences. Dermatologists ranked their preferences at the end of the study. Results: In-person examinations were preferred by both patients and dermatologists. Overall, satisfaction with teledermatology was still high. Patients were evenly divided in preferring store-and-forward workups or live interactive video. Dermatologists were also divided on store-and-forward and uncompressed video, but tended toward the latter. Compressed video was the least preferred method among dermatologists. Limitations: Dermatology residents took store-and-forward photos and their quality was likely superior to those normally taken in practice. Conclusions: Patients and dermatologists prefer in-person examinations and diverge on preferring store-and-forward and live interactive when video is not compressed. The amount of video compression that can be applied without noticeable image degradation is a question for future research.

Markun et al (2017) Mobile teledermatology for skin cancer screening: A diagnostic accuracy study83

Skin cancer screening has undoubted potential to reduce cancer-specific morbidity and mortality. Total-body exams remain the prevailing concept of skin cancer screening even if effectiveness and value of this method are controversial. Meanwhile, store and forward teledermatology was shown to be a reliable instrument for several diagnostic purposes mostly in specialized dermatology settings. The objective of this study was to evaluate most convenient mobile teledermatology interventions as instruments for skin cancer screening in a representative population. Prospective diagnostic study with visitors of a skin cancer screening campaign in Switzerland. Histopathology was used as reference standard. Mobile teledermatology with or without dermoscopic images was assessed for performance as a screening test: ie rule-in or rule-out the need for further testing. Outcomes were sensitivity, specificity, and predictive values.Seven cases of skin cancer were present among 195 skin lesions. All skin cancers were ruled-in by teledermatology with or without dermoscopic images (sensitivity and negative predictive value 100%). The addition of dermoscopic images to conventional images resulted in higher specificity (85% vs. 77%), allowing reduction of unnecessary further testing in a larger proportion of skin lesions. Store and forward mobile teledermatology could serve as an instrument for population-based skin cancer screening because of favorable test performance.

O’Toole et al (2017) The association between question type and the outcomes of a Dermatology eConsult service84

Background: eConsult is a web based service that facilitates communication between primary care providers (PCPs) and specialists, which can reduce the need for face-to-face consultations with specialists. One example is the Champlain BASE (Building Access to Specialist through eConsultation) service with dermatology being the largest specialty consulted. Methods: Dermatology eConsults submitted from July 2011 to January 2015 were reviewed. Post eConsult surveys for PCPs were analyzed to determine the number of traditional consults avoided and perceived value of eConsults. The time it took the PCP to receive a reply and the amount of time reported by the specialist to answer eConsult were proactively recorded and analyzed. A subset of 154 most recent eConsults was categorized for dermatology content and question type [eg diagnosis or management]using a validated taxonomy. Results: A total of 965 eConsults were directed to dermatology from 217 unique PCPs. The majority of eConsults (64%)took the specialist between 10 and 15 minutes to answer. The overall value of this service to the provider was rated as very good or excellent in 95% of cases. In 49%, traditional inperson assessments were avoided. In the subset of the most recent cases, diagnosis was the most common question type asked (65.2%)followed by management (29%) and drug treatment (10.6%). The top five subject areas (40%) were: Dermatitis, Infections, Neoplasm, Nevi, and Pruritus. Conclusion: eConsults was feasible and well received by PCPs, which improves access to dermatology care with a potential to reduce wait times for traditional consultation.

Wang et al (2017) Diagnosis and Management of Malignant Melanoma in Store-and-Forward Teledermatolog85

Background: Published studies have led to concern that store-and-forward teledermatology (SFT) diagnosis and management of melanomas may be inferior to face-to-face (FTF) dermatology care. Introduction: To ascertain the frequency of correctly managed and diagnosed melanomas within a population of veterans in Veterans Integrated Service Network 20 SFT. Materials and methods: We conducted a retrospective chart review of 7,960 veterans seen by SFT between July 1, 2009 and December 31, 2011. Results: Of the 61 veterans that met inclusion and exclusion criteria, 45 (74%) melanomas were correctly diagnosed and 57 (93%) were correctly managed. Discussion: Diagnostic and management accuracy of SFT is comparable to FTF. Incorrect diagnosis or management of melanomas did not prove to have significant consequences for patient care. Cases subject to analysis of this study are not demographically representative of the general population. Conclusion: Diagnosis and management of melanoma in SFT is comparable to FTF care.

Witkowski et al (2017) Improving diagnostic sensitivity of combined dermoscopy and reflectance confocal microscopy imaging through double reader concordance evaluation in telemedicine settings: A retrospective study of 1000 equivocal cases86

Background: Reflectance confocal microscopy (RCM)is an imaging device that permits non-invasive visualization of cellular morphology and has been shown to improve diagnostic accuracy of dermoscopically equivocal cutaneous lesions. The application of double reader concordance evaluation of dermoscopy-RCM image sets in retrospective settings and its potential application to telemedicine evaluation has not been tested in a large study population. Objective: To improve diagnostic sensitivity of RCM image diagnosis using a double reader concordance evaluation approach; to reduce mismanagement of equivocal cutaneous lesions in retrospective consultation and telemedicine settings. Methods: 1000 combined dermoscopy-RCM image sets were evaluated in blind by 10 readers with advanced training and internship in dermoscopy and RCM evaluation. We compared sensitivity and specificity of single reader evaluation versus double reader concordance evaluation as well as the effect of diagnostic confidence on lesion management in a retrospective setting. Results: Single reader evaluation resulted in an overall sensitivity of 95.2% and specificity of 76.3%, with misdiagnosis of 8 melanomas, 4 basal cell carcinomas and 2 squamous cell carcinomas. Combined double reader evaluation resulted in an overall sensitivity of 98.3% and specificity of 65.5%, with misdiagnosis of 1 in-situ melanoma and 2 basal cell carcinomas. Conclusion: Evaluation of dermoscopy-RCM image sets of cutaneous lesions by single reader evaluation in retrospective settings is limited by sensitivity levels that may result in potential mismanagement of malignant lesions. Double reader blind concordance evaluation may improve the sensitivity of diagnosis and management safety. The use of a second check can be implemented in telemedicine settings where expert consultation and second opinions may be required.

Arzberger et al (2016) Teledermoscopy in High-risk Melanoma Patients: A Comparative Study of Face-to-face and Teledermatology Visits87

Teledermoscopy is considered a reliable tool for the evaluation of pigmented skin lesions. We compared the management decision in face-to-face visits vs. teledermatology in a high-risk melanoma cohort using total-body photography, macroscopic and dermoscopic images of single lesions. Patients were assessed both face-to face and by 4 remote teledermatologists. Lesions identified as suspicious for skin cancer by faceto-face evaluation underwent surgical excision. The teledermatologists recommended self-monitoring, short-term monitoring, or excision. A 4-year monitoring was completed in a cohort of participating subjects. The general agreement, calculated by prevalence and bias-adjusted κ(PABAK), showed almost perfect agreement (PABAK 0.9-0.982). A total of 23 lesions were excised; all teledermatologists identified the 9 melanomas. The greatest discrepancy was detected in “short-term monitoring”. During 4-year monitoring one melanoma was excised that had been considered benign. In conclusion, melanoma identification by experts in pigmented lesions appears to be equivalent between face-to-face and teledermatological consultation.

Chen et al (2016) Validation of a Skin-Lesion Image-Matching Algorithm Based on Computer Vision Technolog88

Background: Melanoma incidence is increasing globally, but consistently accurate skin-lesion classification methods remain elusive. We developed a simple software system to classify potentially all types of skin lesions. In the current study, we evaluated the system’s ability to identify melanomas with a diameter of 10 mm or larger. Materials and methods: The skin-lesion classification system is composed of a proprietary database of nearly 12,000 diagnosed skin-lesion images and a computer algorithm based on the principles of content-based image retrieval. The algorithm compares characteristics of new skin-lesion images with images in the database to identify the nearest-match diagnosis. Results: Nearly all classification accuracy measures for this new system exceeded 90%, with results for sensitivity of 90.4% (95% confidence interval, 85.6-93.7%), specificity of 91.5% (85.4-95.2%), positive predictive value of 94.5% (90.4-96.9%), negative predictive value of 85.5% (78.7- 90.4%), and overall classification accuracy of 90.8% (87.2-93.4%). Conclusions: The image-matching algorithm performed with high accuracy for the classification of larger melanomas. Furthermore, the system does not require a dermoscope or any other specialized hardware; any closefocusing camera will do. This system has the potential to be an inexpensive and accurate tool for the evaluation of skin lesions in ethnically and geographically diverse populations.

De Giorgi et al (2016) Teledermoscopy in doubtful melanocytic lesions: is it really useful?89

Introduction: The diagnosis of cutaneous pigmented lesions remains a challenge for both dermatologists and pathologists. Our aim was to determine the diagnostic concordance between the conventional face-toface diagnosis and the telediagnosis of 10 dermatologists with expertise in dermato-oncology of 10 challenging pigmented lesions. Methods: Using a store-and-forward teledermatology method, clinical and dermoscopic digital images of all selected lesions were transmitted via email to 10 dermatologists. Dermatologists were called to provide their telediagnoses with a step-by-step approach. When the dermatologists responded with their first clinical telediagnosis, they received a second email that contained dermoscopic images of the 10 cases. Final histopathological diagnosis was considered the gold standard for comparison with face-toface and teledermatology diagnoses in statistical analysis. Results: Face-to-face results indicated moderate agreement between clinical and histopathological diagnoses (K = 0.6). After the first clinical step, interobserver concordance of telediagnosis was lower than face-to-face diagnosis (K = 0.52). After the second dermoscopy step, the concordance declined further (K = 0.38). Conclusions: Teledermatology was inferior to face-to-face dermatology. Moreover, the diagnostic concordance of telediagnosis decreased after the teledermoscopic step. This finding may be justified by the dermoscopic difficulty of the selected lesions, including Spitzoid proliferations and atypical melanocytic nevi of the elderly. These lesions may represent a potential diagnostic pitfall given their confounding dermoscopic aspects.

Bashshur et al (2015) The Empirical Foundations of Teledermatology: A Review of the Research Evidence90

Introduction: This article presents the scientific evidence for the merit of telemedicine interventions in the diagnosis and management of skin disorders [teledermatology]in the published literature. The impetus for this work derives from the high prevalence of skin disorders, the high cost, the limited availability of dermatologists in certain areas, and the promise of teledermatology to address unmet needs in this area. Materials and Methods: The findings are based on a targeted review of scientific studies published from January 2005 through April 2015. The initial search yielded some 5,020 articles in Google Scholar and 428 in PubMed. A review of the abstracts yielded 71 publications that met the inclusion criteria for this analysis. Evidence is organized according to the following: feasibility and acceptance; intermediate outcomes [use of service, compliance, and diagnostic and treatment concordance and accuracy]; outcomes [health improvement and problem resolution]; and cost savings. A special section is devoted to studies conducted at the Veterans Health Administration. Results: Definitions of teledermatology varied across a wide spectrum of skin disorders, technologies, diagnostic tools, provider types, settings, and patient populations. Outcome measures included diagnostic concordance, treatment plans, and health. Conclusions: Despite these complexities, sufficient evidence was observed consistently supporting the effectiveness of teledermatology in improving accessibility to specialty care, diagnostic and treatment concordance, and skin care provided by primary care physicians, while also reducing cost. One study reported suboptimal clinical results from teledermatology for patients with pigmented skin lesions. On the other hand, confocal microscopy and advanced dermoscopy improved diagnostic accuracy, especially when rendered by experienced teledermatologists.

Ford and Pereiria (2015) Does teledermatology reduces secondary care referrals and is it acceptable to patients and doctors? A service evaluation91

Rationale, aims and objectives: Referrals to dermatology for skin lesions is increasing. Teledermatology allows patients to obtain specialist advice remotely. The aim of this study is to assess if teledermatology reduces secondary care dermatology referrals and evaluate its acceptability to patients and clinicians. Methods: A 24-month before and after comparative evaluation of a teledermatology service was undertaken involving four non-randomly allocated intervention practices and 18 control practices. Referral data for 12 months before and after the introduction of teledermatology was compared in intervention and control practices. Patient questionnaires explored their satisfaction and structured user dialogues explored the usefulness and benefits to clinicians. Time series analysis, adjusted for age and sex, was undertaken to assess the impact on secondary care referrals. Results: There were 195 Telederm referrals during the 12-month pilot period. Seborrhoeic keratosis was the commonest diagnosis. No action was required in 86 patients. Urgent referral to secondary care was recommended in 64 patients and routine referral in 19. The difference in referral rate before and after was +2.11 referrals per 1000 practice population in the teledermatology group and +1.39 in the control group. This was statistically significant in the adjusted, but not unadjusted, analysis. There was a 14% response rate for the questionnaire. The service was very popular with patients and clinicians. Clinicians highlighted the significant educational benefit. Conclusion: We did not find any evidence that teledermatology reduced secondary care referral rates but in this small pilot, we found that it increased referrals in the short term. It was very popular among patients and clinicians, especially for its educational value.

Wu et al (2015) Feasibility and Efficacy of Patient-Initiated Mobile Teledermoscopy for Short-term Monitoring of Clinically Atypical Nevi92

Importance: Patient-driven mobile teledermoscopy may be applicable for monitoring of skin lesions. Objective: To assess the feasibility, efficacy, and patient receptivity of teledermoscopy for short-term monitoring of clinically atypical nevi. Design, setting, and participants: This was a prospective cohort study performed at an institutional referral center in New York. Consecutive patients 18 years or older, with 1 or more clinically atypical nevi that required short-term monitoring and were accessible by a mobile imaging device were recruited for the study. All 34 patients consented to the study, and 29 completed follow-up. Dermoscopic images were obtained in the officebased setting by a dermatologist and with an iPhone by the patient at baseline and follow-up [3-4 months]. Patients completed surveys that included questions about skincare awareness and attitudes toward teledermoscopy. Standard dermoscopic images were evaluated by the office-based dermatologist, and mobile dermoscopic images were sent via the Internet to a teledermatologist to evaluate image quality and presence of significant clinical lesion change. The decisions of the teledermatologist and office-based dermatologist were compared.

Main Outcomes and Measures: 1. feasibility of using mobile dermatoscope by patients; 2. diagnostic concordance of teledermoscopy vs conventional office-based visit; and 3. patient receptivity to teledermoscopy for shortterm monitoring of nevi. Results: Of the 29 patients who completed the study, 28 (97%) were able to acquire baseline and follow-up images that were subsequently deemed evaluable by the teledermatologist. The diagnostic concordance between conventional office-based visits and teledermoscopy encounters was 0.87 (SE, 0.13)(κ statistic). In addition, patients reported high receptivity to teledermoscopy for short-term monitoring of nevi. Conclusions and Relevance: Results from this pilot study suggest that teledermoscopy is feasible and effective as a method for short-term monitoring of clinically atypical nevi. The implementation of teledermoscopy can potentially enhance patient convenience, optimize physician scheduling, and promote efficiency.

Pediatric Dermatology

Randomised Controlled Trials

O’Connor et al (2017) [Randomised Controlled Trial] Diagnostic Accuracy of Pediatric Teledermatology Using Parent-Submitted Photographs: A Randomized Clinical Trial93

Importance: Advances in smartphone photography both quality and image transmission may improve access to care via direct parent-to-clinician telemedicine. However, the accuracy of diagnoses that are reliant on parentprovided photographs has not been formally compared with diagnoses made in person. Objective: To assess whether smartphone photographs of pediatric skin conditions taken by parents are of sufficient quality to permit accurate diagnosis. Design, Setting, and Participants: A prospective study was conducted among 40 patient-parent dyads at a pediatric dermatology clinic at the Children’s Hospital of Philadelphia from March 1 to September 30, 2016, to assess concordance between diagnoses made by an independent pediatric dermatologist based on in-person examination and those based on parental photographs. Half of the patient-parent dyads were randomized for a secondary analysis to receive instructions on how best to take photographs with smartphones. Clinicians were blinded to whether parents had received photography instructions. Exposures: Half of the patient-parent dyads received a simple, 3-step instruction sheet on how best to take photographs using a smartphone [intervention group]; the other half did not [control group].

Main Outcomes and Measures: Concordance between photograph-based vs in-person diagnosis in the intervention vs control groups, as quantified using Cohen κ, a measure of interrater agreement that takes into account the possibility of agreement occurring by chance.

Results: Among the 40 patient-parent dyads (22 female children and 18 male children; mean [SD] age, 6.96 [5.23] years), overall concordance between photograph-based vs in-person diagnosis was 83% (95% CI, 71%-94%; κ = 0.81). Diagnostic concordance was 89% (95% CI, 75%-97%; κ= 0.88)in a subgroup of 37 participants with photographs considered of high enough quality to make a diagnosis. No statistically significant effect of photography instructions on concordance was detected (group that received instructions, 85%; group that did not receive instructions, 80%; P = .68). In cases of diagnostic disagreement, appropriate follow-up was suggested.

Conclusions and Relevance: Parent-operated smartphone photography can accurately be used as a method to provide pediatric dermatologic care.


Bettloch-Mas et al (2020) [Descriptive Study] Teledermatology in paediatrics: Health-care impact on the early treatment of infantile haemangiomas94

Introduction: Teledermatology can solve diagnostic and therapeutic problems in paediatrics, for example in infantile haemangiomas (IHs) requiring early treatment with propranolol. This study aims to assess the impact of teledermatology following its implementation in a health area of Spain, specifically analysing its effectiveness in reducing the age of first propranolol treatment for IH. Methods:This was a descriptive study of paediatric teledermatology from 2015 to 2018, studying age, sex, diagnosis, time and mode of resolution. All IHs referred via teledermatology were analysed, and age at propranolol initiation was compared to the period prior to implementation (2008-2014). We also analysed IHs according to referral pathways: teledermatology vs. conventional pathways. Results:We included 432 consultations (47.7% boys). The main diagnoses were IH, erythematous-desquamative diseases and infections. Concordance in diagnosis between paediatricians and dermatologists was good, and 48.12% of cases consulted via teledermatology were resolved remotely. Response time was 2.81 days on average. Children younger than two months of age showed the highest proportion of in-person visits. In 2015-2018, children with IHs began treatment with propranolol at a mean age of 4.5 months [1.9 months in those referred via teledermatology vs. 5.6 months in those using conventional referral pathways]. In 2008-2014, the mean age at referral was 7.1 months. These differences were significant. Discussion: Teledermatology is a fast and effective tool to resolve paediatric cases, enabling a significant decrease in the age of treatment in infants with IH.

Frieden et al (2020) Management of infantile hemangiomas during th COVID pandemic95

The COVID-19 pandemic has caused significant shifts in patient care including a steep decline in ambulatory visits and a marked increase in the use of telemedicine. Infantile hemangiomas (IH) can require urgent evaluation and risk stratification to determine which infants need treatment and which can be managed with continued observation. For those requiring treatment, prompt initiation decreases morbidity and improves long-term outcomes. The Hemangioma Investigator Group has created consensus recommendations for management of IH via telemedicine. FDA/EMAapproved monitoring guidelines, clinical practice guidelines, and relevant, up-to-date publications regarding initiation and monitoring of beta-blocker therapy were used to inform the recommendations. Clinical decision-making guidelines about when telehealth is an appropriate alternative to in-office visits, including medication initiation, dosage changes, and ongoing evaluation, are included. The importance of communication with caregivers in the context oftelemedicine is discussed, and online resources for both hemangioma education and propranolol therapy are provided.

Gehris and Herman (2020) [Review] Pediatric Teledermatology: a Review96

Purpose of Review: Only a small number of dermatologists are also certified in pediatric dermatology by the American Board of Dermatology, creating an access barrier that is amenable to teledermatology. More than 50% of pediatric dermatologists currently practice teledermatology, but there is a dearth of literature validating the collective experience. This article reviews teledermatology terminology and summarizes the recent literature supporting pediatric teledermatology’s diagnostic accuracy, efficacy, usability and cost-effectiveness. Recent findings: Diagnoses rendered using pediatric teledermatology share high concordance rates with in-person diagnoses. While most dermatologists prefer store and forward compared to real-time interactive teledermatology, a hybrid model may be advantageous for complex cases. Physician-to-physician teledermatology is ideal for pediatric inpatient and outpatient consultations, while direct-topatient teledermatology may be more efficient for non-emergent pediatric outpatient visits. Eczema, acne, rashes and birthmarks lend themselves better to teledermatology than do pigmented lesions. Summary: This article summarizes the recent literature addressing the current state of pediatric teledermatology and reviews terminology, care models, pediatric best practices and benefits as well as challenges.

Seiger et al (2020) [Retrospective Cohort Study] Pediatric dermatology eConsults: Reduced wait times and dermatology office visits97

Background and Objectives: Store-and-forward teledermatology provides pediatricians with specialist guidance in managing skin disease. This study evaluates wait times and face-to-face (FTF) dermatology visit avoidance associated with a pediatric dermatology eConsult program at an urban academic medical center. Methods: In this retrospective cohort study, electronic medical records were reviewed for patients under age 18 for whom a dermatology eConsult was completed between November 1, 2014, and December 31, 2017. Wait times for eConsult completion and initial FTF dermatology appointments were calculated and compared to average wait times for new patient dermatology office appointments from 2016 to 2017. Recommendations for FTF dermatology visits were assessed, along with FTF visit attendance and potential cost savings. Results:One hundred eighty pediatric patients with 188 unrelated skin conditions were referred to the program. Of 188 cases, FTF dermatology visits were recommended for 60 (31.9%). Actual FTF dermatology visit avoidance was 53.7% of total cases [n = 101 for whom FTF visit was not recommended and no dermatology visit occurred within 90 days after eConsult submission]. The program generated potential savings of $24,059 in 2016 dollars. Average turnaround for eConsult completion was 1.8 calendar days (median: 1 calendar day;target: 2 business days). Average wait time to initial FTF dermatology evaluation was 37.3 calendar days versus 54.1 days for pediatric patients referred directly to dermatology clinic between 2016 and 2017. Conclusion:Pediatric dermatology eConsults reduce wait times for specialist care, triage cases for in-office evaluation, reduce need for FTF dermatology visits, and offer potential cost savings for payers and patients.

Giavina Bianchi et al (2019) [Cross-Sectional Retrospective Study] The majority of skin lesions in pediatric primary care attention could be managed by Teledermatology98

Background: Teledermatology is a tool that provides accurate diagnosis and has been gaining more emphasis over time. It can be used for triage in primary care attention to address skin conditions improving access and reducing time to treatment for surgical, severe or even lethal diseases. Objectives:Our main goal was to evaluate the proportion of pediatric patient’s lesions that could be managed using teledermatology in primary care attention. Secondly, we wanted to assess the ten most frequent skin conditions, the most common treatments and the referrals made by the teledermatologists to biopsy, in-presence dermatologist or kept at primary care attention.

Methods:A cross-sectional retrospective study involving 6,879 individuals and 10,126 lesions was conducted by store-and-forward teledermatology during one year in the city of Sao Paulo, Brazil. If the photographs taken had enough quality, teledermatologist would diagnose, treat and orient each lesion, if possible, and choose one of three options for referral: direct to biopsy, in-presence dermatologist or kept at primary care attention. Results: Teledermatology managed 62% of the lesions to be kept at primary care attention, 37% were referred to dermatologists and 1% to biopsy, reducing the mean waiting time for an in-presence visit in 78%. In patients 0- 2 years old, lesions related to eczema and benign congenital lesions predominated. From 3-12 years old, eczema was still a major cause of complaint, as well as warts and molluscum. From 13-19 years old, acne was the most significant problem, followed by atopic dermatitis, nevi and warts. The most frequent treatment was emollient. Conclusion:Teletriage addressed 63% of the lesions without the need for an in-presence visit, suggesting that teledermatology can manage common diseases and optimize dermatological appointments for the most serious, surgical or complex skin illnesses, reducing the mean waiting time for them.

Fiks et al (2018) Usability, Acceptability, and Impact of a Pediatric Teledermatology Mobile Health Application99

Objective: Pediatric dermatology appointment wait times often exceed several months. We evaluated the usability, acceptability, and clinical impact of a store-and-forward teledermatology mobile application linking families with pediatric dermatologists. Methods: Parents of children age 6 weeks to 17 years or individuals 18-21 years old were invited by e-mail or referral to participate in this single group, prospective study. Within the app, users photographed the skin condition, answered questions, and submitted their case for review. One pediatric dermatologist viewed cases, diagnosed conditions, and provided instructions and prescriptions. User surveys immediately following app use and 1 week later, supplemented by electronic logs, assessed usability, acceptability, and impact. Results: One hundred ninety-seven parents and one adolescent submitted cases within 39 days of invitation. App users were more likely to be white than those in the population invited (67% vs. 34%, p < 0.001) and their children were slightly younger (mean 7.3 vs. 9.0 years, p < 0.001). A majority, 83% found the app easy to use, 97% felt that submitting a case took the right amount of time, 87% were satisfied, and 93% would use the app again. Prescription receipt was associated with increased app satisfaction (p = 0.008). The median user received a response in 2.8 h [interquartile range 1.1- 6.4]. Had the app been unavailable, 44% reported that they would have waited for primary care, 32% for a dermatology appointment, and 7% would have gone to an urgent care clinic. Conclusions: A mobile health app allowing families to directly consult a pediatric dermatologist was usable, acceptable, and expedited care.

Feigenbaum et al (2017) Can You See Me Now? Video Supplementation for Pediatric Teledermatology Cases100

Background:Digital video is widely available and is used sporadically in clinical settings to evaluate patients, but whether it helps improve clinical management has not been determined. The aim of this study was to assess whether recorded video in addition to still images can improve residents’ diagnostic and management accuracy and confidence with pediatric teledermatology cases. Methods:Dermatology residents from three programs were assigned alternately to an online survey with 15 pediatric teledermatology cases presented with still images only or still images plus recorded video. Participants provided free-text diagnoses and management recommendations and rated their confidence and image quality. Responses were scored using a modified script concordance grading key based on reference panelists’ responses. Results: Thirty-one residents participated (response rate 57%). Participants in the mixed group scored significantly higher on management accuracy (87.6 ± 12.9 vs 71.7 ± 14.2; p = 0.003). Both groups performed better on more common conditions than less common conditions. The mixed group outperformed the still group on less common conditions with respect to management recommendations. Conclusion: This novel study suggests that supplemental recorded video may improve the management accuracy of pediatric teledermatology consultations, particularly for complex cases. Residents may benefit from training in recording and interpreting video.

Naka et al (2017) Teledermatology: Kids are not just little people101

Teledermatology has emerged as a promising solution for pediatric and adult patients accessing dermatologic care in a health care environment fraught with barriers to access. Teledermatology has been extensively evaluated in terms of diagnostic accuracy, clinical outcomes, patient and provider satisfaction, and costs, relative to traditional health care delivery models. Current research indicates that teledermatology is effective and efficient in diagnosis and management of skin diseases. The majority of studies on the subject, however, rely on adult patient data. Pediatric patients, with their unique clinical features and challenges, may interact with telemedicine differently than their adult counterparts. Maximizing the benefits of teledermatology in pediatric dermatologic care is dependent on future research. We review and analyze the commonalities and differences between pediatric and adult patient care using teledermatology.

Fogel et al (2016) Direct-to-consumer teledermatology services for pediatric patients: Room for improvement102

Direct-to-consumer teledermatology is radically changing the way some patients obtain dermatologic care. Many direct-to-consumer teledermatology services offer care to patients younger than 18 years, but policies and standards are nonuniform. For pediatric patients, direct-toconsumer teledermatology is a substantial departure from in-person care. More consensus, standards, and guidelines are necessary.

Fogel and Teng (2015) Pediatric teledermatology: a survey of usage, perspectives, and practice103

Pediatric dermatology is one of the smallest subspecialties, and expanding the availability of care is of great interest. Teledermatology has been proposed as a way to expand access and improve care delivery, but no current assessment of pediatric teledermatology exists. The objective of the current study was to assess usage and perspectives on pediatric teledermatology. Surveys were distributed electronically to all 226 boardcertified U.S. pediatric dermatologists; 44% (100/226) responded. Nearly all respondents (89%) have experience with teledermatology. Formal teledermatology reimbursement success rates have increased to 35%. Respondents were positive about teledermatology’s present and future prospects, and 41% want to use teledermatology more often, although they viewed teledermatology as somewhat inferior to in-person care regarding accuracy of diagnosis and appropriation of management plans. Significant differences were found between formal teledermatology users and nonusers in salary structure, practice environment, sex, and region. Substantial increases in pediatric teledermatology have occurred in the last 5 to 10 years, and there remains cause for optimism for teledermatology’s future. Concerns about diagnostic confidence and care quality indicate that teledermatology may be best for care of patients with characteristic clinical presentations or management of patients with established diagnoses.

Karlsson et al (2015) Mobile teledermatology is a valid method to estimate prevalence of melanocytic naevi in children104

The prevalence of melanocytic naevi in children correlates with sun exposure and may serve as an objective population risk indicator of future melanoma incidence. The aim was to investigate if mobile teledermatology could offer a valid methodology compared with standard manual, face-toface counting of naevi on the back of children. Ninety-seven children aged 7- 16 years were enrolled. One dermatologist performed manual naevi counting and imaging of the child’s back using an iPhone 4S comprising a safe-coded mobile application. Two other dermatologists independently counted naevi from the images. Cohen’s weighted kappa (κw) coefficient demonstrated substantial agreement for both dermatologists: κw = 0.69 (0.57-0.81 [95% confidence intervals]) and κw = 0.78 (0.70-0.86), compared with the manual assessment. Inter-rater reliability was also substantial (κw = 0.80 [0.73- 0.87]). Use of mobile teledermatology proved valid for estimating naevi prevalence on the back and could provide a more feasible methodology following trends in sun exposure in children.

Paradela-De-La-Morena et al (2015) [Retrospective Cohort Study]Teledermatology: diagnostic reliability in 383 children105

Background:There are few studies of teledermatology focused on the pediatric age group. The aim of this study was to assess the validity and reliability of store-and-forward teledermatology (STD) as a diagnostic tool for pediatricians and to reduce face-to-face consultations. Material and Methods:A retrospective, observational study of 383 children and adolescents under 15 years of age, referred from primary care to Dermatology Department of University Hospital of La Coruña, Spain, between 2011 and 2013, using a STD consult system. Results:Diagnoses concordance between pediatricians and teledermatologists was 39.2% of cases and partial concordance 16.7%. Agreement for global diagnosis was κ = 0.78 (p = 0.000) and for specific diagnosis was κ = 0.73 (p = 0.000). Management was concordant in 28.7% and partially concordant in 15.4%. Lower reliability was statistically associated with modification of the lesions by inappropriate treatments, incomplete clinical data or bad-quality photographic images included in the referral consultation, diagnosis of infectious diseases and rare dermatoses. The filtering percentage as the percentage of avoided clinic-based evaluations was 64.5%. The mean response time of the consultant dermatologists was 3.62 days. Referrals for live consultations due to poor clinical information or insufficient quality of pictures were necessary in only 10% of the cases. Conclusion:The degree of diagnostic accuracy for the pediatric population using STD as a diagnostic tool was similar to that achieved in adults. Its usefulness for filtering dermatologic referral was also demonstrated in the study, so it could be suitable for integration into the routine practice of pediatricians.

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