Teledermatology

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Teledermatology is a subspecialty in the medical field of dermatology and probably one of the most common applications of telemedicine and e-health.[1] In teledermatology, telecommunication technologies are used to exchange medical information (concerning skin conditions and tumours of the skin) over a distance using audio, visual and data communication. Applications comprise health care management such as diagnoses, consultation and treatment as well as (continuous) education.[2]

The dermatologists Perednia and Brown were the first to coin the term “teledermatology” in 1995. In a scientific publication, they described the value of a teledermatologic service in a rural area underserved by dermatologists.[3]

Modes of data transmission[edit]

Teledermatology (as telemedicine) is practised on the basis of two concepts: Store and forward (SAF) and real time/live interactive teledermatology. Hybrid modes also exist (combining SAF and real time applications).

The SAF method is most commonly used in teledermatology: It involves sending (forwarding) digital images associated with (anonymous) medical information to the data storage unit of a consulted specialist. It can be as easy as sending an email with a digital image of a lesion to seek advice for a skin condition. Advantages of this method are that it does not demand the presence of both parties at the same time and does not usually require expensive equipment.

In real-time/ live interactive teledermatology applications, provider and individuals usually interact via live videoconferencing. It may also involve remote surgery and the use of telerobotic microscopes in dermatopathology. This mode generally requires more sophisticated and costly technology than used in the SAF mode. Both participants must be available at the same time.

Areas of application[edit]

Health care management[edit]

Telemedicine developed by Remote meeting Technologies (RMT) substantially reduces the cost of Telediagnosis and telecommunication. Remote Meeting Technologies’ real-time, full-HD telepathology solution benefits everyone involved. From the pathologists who do the work, to administrators who pay the bills, to the IT department maintaining security and reliability and most of all the patients, whose well-being is the ultimate concern. RMT currently delivers real time solutions to many medical facilities throughout the United States and Canada. Remote Meeting Technologies, true high-definition, brilliant color, high-definition video allows pathology for both gross and microscopic imaging. True 1920 x 1080p resolution is shared realtime over standard networks. The next generation of diagnostics is now being provided world wide.

Health care management[edit]

Direct consultation involves an individual with a skin condition contacting a dermatologist via telecommunication to request diagnosis and treatment. In this field, mobile applications of teledermatology gain importance.

Telediagnosis in the absence of personal contact with health care workers to the individual is complex. It requires active participation of the individual and without appropriate guidance may lead to improper management. However, as a triage tool, leading the individual directly to the appropriate specialist for his/her disease, it could be very valuable in the near future.

Specialist referral is a major area of application in teledermatology A general practitioner (or other medical professional) that sees the individual consults a specialist/ specialised centre via telecommunication in order to get a second opinion. The specialist then helps the GP in rendering a diagnosis, providing management options et cetera.[4]

Home telehealth/telehomecare involves an individual with a chronic condition being examined and managed remotely at home. An important field of interest of telehomecare in dermatology is the follow-up treatment of individuals with skin conditions requiring regular follow-up such as crural ulcers. Crural ulcers are a common skin condition that needs follow up visits up to twice a week demanding significant time commitments by the individuals in addition to causing a financial burden on the health care system. Teledermatology can help to reduce the time and costs involved in the follow-up of such conditions.[5]

Education and information[edit]

Medical education/continuous education are a major advantage of telemedicine/e-health. Numerous universities offer online courses, computer based training and Web applications in this field principally aimed at medical students. Specialist training courses via internet are also available, particularly in dermoscopy.[6]

General medical/health information may be accessed by non-professionals, such as individuals affected by a skin condition, and their relatives, through the internet. They are also able to join peer support groups with others affected by the same condition.[7]

Domains with special interest[edit]

Teledermoscopy[edit]

In teledermoscopy, digital dermoscopic lesion images (with or without clinical images) are transmitted electronically to a specialist for examination. This can be done on the web-based telediagnostic network Campus Medicus

Dermoscopy (dermatoscopy, epiluminescence microscopy) is the technical field of using an epiluminescence microscope for viewing skin lesions in magnification in-vivo. It is particularly useful in the early detection of malignant skin lesions (i.e., melanoma). Digital dermoscopic images can be taken with a digital camera attached to a dermatoscope or special video cameras suited for dermoscopy, e.g. the FotoFinder. Since dermoscopy is based on examination of a two-dimensional image it is very well suited for digital imaging and teledermatology.

Teledermatopathology[edit]

Teledermatopathology is the transmission of dermatopathologic images either in real-time with the aid of a robotic microscope or using a store-and-forward system (transmission as a single file). In the latter method (SAF) a rather new development is the introduction of virtual slide systems (VSS).[8]

Virtual slides are made by digitally scanning an entire glass slide at a high resolution and then sending the images to a storage system. These can be then assessed on a computer screen similar to conventional microscopy, allowing the pathologist to maneuver around the image and view every part of the slide at any magnification.

Teledermoscopically-aided dermatopathology[edit]

This is the transmission of crucial medical data and dermoscopic as well as clinical images to a pathologist who renders the conventional histopathologic diagnosis.

In the everyday clinical setting, skin biopsies are taken by the physician directly responsible for the individual and are assessed by a dermatopathologist. This pathologist has most likely never seen the clinical aspect of the lesion and might not have any information about the person. These limitations can be overcome by teledermoscopically-aided dermatopathology whereby a patient history and clinical data may increase the sensitivity of diagnosis.[9]

Additionally it has been shown that provision of such data may improve the level of diagnostic confidence held by the assessing dermatopathologists.

Mobile Teledermatology[edit]

Mobile telemedicine is a system in which at least one participant (the person seeking advice or the doctor, for instance) uses wireless or mobile equipment[10] (i.e. mobile phones, handheld devices), in contrast to conventional stationary telemedicine platforms. Travellers who develop skin lesions as well as doctors who are on the move in hospital/non-hospital area can benefit from this new development in teledermatology. In order to facilitate access to medical advice and enable individuals to play a more active role in managing their own health status, mobile teledermatology seems to be especially suited for patient filtering or triage. (i.e. referral based on the severity and character of their skin condition). Another possible practical application is for follow-up of individuals with chronic skin conditions.

Suitability of cases for Teledermatology[edit]

Not all cases are suitable for teledermatology.The type of cases suited for teledermatology is a topic, which requires more studies. Some studies have observed that eczema and follicular lesions were diagnosed with relatively more certainty,while in some other studies it was seen that diagnoses were made with more certainty in cases like viral warts, herpes zoster, acne vulgaris, irritant dermatitis, vitiligo, and superficial bacterial and fungal infections. Unlike in western studies where pigmented lesions suspicious of melanomas are one of the most referred cases for teledermatology (with or without teledermatoscopy), Asian studies have fewer cases referred based on the suspicion of melanoma.[11]

Implemented Projects by Country[edit]

United Kingdom[edit]

24% of the population in England and Wales seek medical advice for a skin condition, and approximately 6% of patients presenting with a skin problem are referred for specialist advice each year.[12]

The Department of Health encourages the use of digital technology in key areas to support delivery of the quality, innovation, productivity, and prevention (QIPP). This includes the introduction of digital or online services to deliver greater convenience for patients and to free up face-to-face clinical time for individuals who really need it.[13]

Vantage Rego is an example of a cloud base application which enables primary care clinicians to capture images of routine dermatological conditions using high quality digital imaging equipment. These images, along with a referral letter, are sent electronically to a dermatology team. Within 3 working days, the referring GP receives a management plan recommending the most appropriate course of treatment based on local resources. Benefits of the service have been highlighted in recent audit [14] and QIPP publications.[15] By 2013, Rego was adopted in over 5% of GP practices in the UK.

See also[edit]

Footnotes[edit]

  1. ^ http://www.atmeda.org/icot/sigtelederm.htm
  2. ^ Wooton et al. 2005 Roy soc of med press; Wurm et al. 2007 JDDG; Burg et al. 2005 Teledermatology
  3. ^ Perednia, Brown 1995 Bull Med Libr Assoc
  4. ^ see http://www.telederm.org/
  5. ^ Binder et al. 2008, Arch Derm
  6. ^ see http://www.medunigraz.at/IDD
  7. ^ see http://www.dermnetnz.org
  8. ^ Massone et al. 2007 Human Pathology
  9. ^ Bauer et al. 2006 Br J Dermatol
  10. ^ http://www.handyscope.net
  11. ^ Kaliyadan et al. 2009 Indian J Dermatol Venereol Leprol
  12. ^ Schofield J, Grindlay D, Williams H. Skin conditions in the UK: a health care needs assessment. Nottingham: Centre of Evidence Based Dermatology, University of Nottingham, 2009.
  13. ^ Department of Health. The operating framework for the NHS in England 2011/12. London: DH, 2010. Available at: www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/@dh/@ en/@ps/documents/digitalasset/dh_122736. pdf (accessed 4 March 2013).
  14. ^ PricewaterhouseCoopers. NHS Hampshire: evaluation of Vantage Teledermatology pilot in Hampshire. London: PricewaterhouseCoopers, 2010.
  15. ^ NHS Bristol. Teledermatology: diagnosis, triage and effective care of dermatology (ID11/0038). London: NHS Evidence, 2012. Available at: www.networks.nhs.uk/news/teledermatology- diagnosis-triage-and-effective-care-of- dermatology

12.^International Society of Teledermatology

13.^Telemedicine in Dermatology

References[edit]

  • R Wootton R, Oakley A: Teledermatology. Royal Society of Medicine Press Ltd, 2002
  • Burg G, Soyer H.P, Chimenti S. (2005): Teledermatology In: Frisch P, Burgdorf W.: EDF White Book, Skin Diseases in Europe. Berlin, 130-133
  • Perednia DA, Brown NA.: Teledermatology: one application of telemedicine. Bull Med Libr Assoc. 1995; 83(1): 42–47
  • Wurm EM, Hofmann-Wellenhof R, Wurm R, Soyer HP.: Telemedizin und Teledermatologie: Vergangenheit Gegenwart und Zukunft. JDDG 6:106-12, 2007
  • Soyer HP, Hofmann-Wellenhof R, Massone C, Gabler G, Dong H, Fezal Ozdemir F, Argenziano G: telederm.org: Freely Available Online Consultations in Dermatology. PLoS Med 2005, 2(4): e87 - see http://dx.doi.org/10.1371/journal.pmed.0020087
  • Binder B, Hofmann-Wellenhof R, Salmhofer W, Okcu A, Kerl H, Soyer HP.: Teledermatological monitoring of leg ulcers in cooperation with home care nurses. Arch Dermatol. 2007 Dec;143(12):1511-4.
  • Ebner C, Gabler G, Massone C, Hofmann-Wellenhof R, Lozzi G P, Wurm EM, Soyer H P.: Mobile Teledermatology coming of age. 2006; e & i. 4:148-151
  • Massone C, Soyer HP, Lozzi GP, Di Stefani A, Leinweber B, Gabler G, Asgari M, BoldrinI R, Bugatti L, Canzonieri V, Ferrara G, Kodama K, Mehregan C, Rongioletti F, * A. Janjua S, Mashayekhi V, Vassilaki I, Zelger B, Žgavec B, Cerroni L, Kerl H.: Feasibility and diagnostic agreement in teledermatopathology using a virtual slide system. Human Pathol. 2007; 38(4): 546-554
  • Bauer J, Leinweber B, Metzler G, Blum A, Hofmann-Wellenhof R, Leitz N, Dietz K, Soyer HP, Garbe C.: Correlation with digital dermoscopic images can help dermatopathologists to diagnose equivocal skin tumours. Br J Dermatol. 2006;155(3):546-51
  • Scheinfeld N, Fisher M, Genis P, Long H. Evaluating Patient Acceptance of a Teledermatology Link. Skinmed. 2003;2:159-167. "PMID 14673291"
  • Kaliyadan F, Venkitakrishnan S. Teledermatology: Clinical case profiles and practical issues. Indian J Dermatol Venereol Leprol 2009;75:32-5.
  • Lipozencić J, Pastar Z, Janjua SA. Teledermatology. Acta Dermatovenerol Croat.2007;15(3):199-201. PubMed PMID 17868546.