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Journal of the American Academy of Dermatology
Volume 61, n° 5
pages 753-765 (novembre 2009)
Doi : 10.1016/j.jaad.2009.04.032
accepted : 17 April 2009
Original Articles

Accuracy of teledermatology for pigmented neoplasms
 

Erin M. Warshaw, MD, MS a, b, , Frank A. Lederle, MD a, Joseph P. Grill, MS a, Amy A. Gravely, MA a, Ann K. Bangerter, BS a, Lawrence A. Fortier, MA a, Kimberly A. Bohjanen, MD b, Karen Chen, MD b, Peter K. Lee, MD, PhD b, Harold S. Rabinovitz, MD c, Robert H. Johr, MD c, d, Valda N. Kaye, MD b, Sacharitha Bowers, MD e, Rachel Wenner, MD b, Sharone K. Askari, MD f, Deborah A. Kedrowski, RN a, David B. Nelson, PhD a
a Minneapolis Veterans Affairs Medical Center, Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota 
b Department of Dermatology, University of Minnesota School of Medicine, Minneapolis, Minnesota 
c Department of Dermatology, University of Miami School of Medicine, Miami, Florida 
d Department of Pediatrics, University of Miami School of Medicine, Miami, Florida 
e Department of Dermatology, Southern Illinois University, Springfield, Illinois 
f Department of Dermatology, St Louis University, St Louis, Missouri 

Correspondence to: Erin M. Warshaw, MD, MS, Department 111 K VAMC, 1 Veterans Drive, Minneapolis, MN 55417.
Abstract
Background

Accurate diagnosis and management of pigmented lesions is critical because of the morbidity and mortality associated with melanoma.

Objective

We sought to compare accuracy of store-and-forward teledermatology for pigmented neoplasms with standard, in-person clinic dermatology.

Methods

We conducted a repeated measures equivalence trial involving veterans with pigmented skin neoplasms. Each lesion was evaluated by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and a management plan. The primary outcome was aggregated diagnostic accuracy (match of any chosen diagnosis with histopathology). We also compared the severity of inappropriately managed lesions and, for teledermatology, evaluated the incremental change in accuracy when polarized light dermatoscopy or contact immersion dermatoscopy images were viewed.

Results

We enrolled 542 patients with pigmented lesions, most were male (96%) and Caucasian (97%). The aggregated diagnostic accuracy rates for teledermatology (macro images, polarized light dermatoscopy, and contact immersion dermatoscopy) were not equivalent (95% confidence interval for difference within ±10%) and were inferior (95% confidence interval lower bound <10%) to clinic dermatology. In general, the addition of dermatoscopic images did not significantly change teledermatology diagnostic accuracy rates. In contrast to diagnostic accuracy, rates of appropriate management plans for teledermatology were superior and/or equivalent to clinic dermatology (all image types: all lesions, and benign lesions). However, for the subgroup of malignant lesions (n = 124), the rate of appropriate management was significantly worse for teledermatology than for clinic dermatology (all image types). Up to 7 of 36 index melanomas would have been mismanaged via teledermatology.

Limitations

Nondiverse study population and relatively small number of melanomas were limitations.

Conclusions

In general, the diagnostic accuracy of teledermatology was inferior whereas management was equivalent to clinic dermatology. However, for the important subgroup of malignant pigmented lesions, both diagnostic and management accuracy of teledermatology was generally inferior to clinic dermatology and up to 7 of 36 index melanomas would have been mismanaged via teledermatology. Teledermatology and teledermatoscopy should be used with caution for patients with suspected malignant pigmented lesions.

The full text of this article is available in PDF format.

Key words : accuracy, melanoma, pigmented lesion, teledermatology, telemedicine



 Supported by the Department of Veterans Affairs Health Services Research and Development Service (Grant IIR 01-072-2). During this study, Dr Warshaw was supported by a Veterans Affairs Cooperative Studies Program Clinical Research Career Development Award.
 Conflicts of interest: None declared.
 Presented in part at the Plenary Session 68th Annual Meeting of the Society of Investigative Dermatology in Los Angeles, CA, on May 10-12, 2007.
 The findings and conclusions presented in this report are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or Health Services Research and Development.
 Reprints not available from the authors.



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