Carrie L. Kovarik

Mobile teledermatology in the developing world: Implications of a feasibility study on 30 Egyptian patients with common skin diseases

BACKGROUND The expansion of store-and-forward teledermatology into underserved regions of the world has long been hampered by the requirement for computers with Internet connectivity. To our knowledge, this study is one of the first to demonstrate the feasibility of teledermatology using newer-generation mobile telephones with specialized software and wireless connectivity to overcome this requirement in a developing country. OBJECTIVE We sought to demonstrate that mobile telephones may be used on the African continent to submit both patient history and clinical photographs wirelessly to remote expert dermatologists, and to assess whether these data are diagnostically reliable. METHODS Thirty patients with common skin diseases in Cairo, Egypt, were given a diagnosis by face-to-face consultation. They were then given a diagnosis independently by local senior dermatologists using teleconsultation with a software-enabled mobile telephone containing a 5-megapixel camera. Diagnostic concordance rates between face-to-face and teleconsultation were tabulated. RESULTS Diagnostic agreement between face-to-face consultation and the two local senior dermatologists performing independent evaluation by teleconsultation was achieved in 23 of 30 (77%) and in 22 of 30 (73%) cases, respectively, with a global mean of 75%. LIMITATIONS Limited sample size and interobserver variability are limitations. CONCLUSION Mobile teledermatology is a technically feasible and diagnostically reliable method of amplifying access to dermatologic expertise in poorer regions of the globe where access to computers with Internet connectivity is unreliable or insufficient.

Human papillomavirus–related genital disease in the immunocompromised host: Part I

Human papillomavirus (HPV) is responsible for common condyloma acuminata and a number of premalignant and malignant anogenital lesions. These conditions are of particular concern in immunocompromised individuals who have higher risk of malignant transformation and are more difficult to treat. This is part I of a two-part review that will highlight the cutaneous features of condyloma acuminata and vaginal, vulvar, penile, and anal intraepithelial neoplasias, with an emphasis on presentation of these HPV-mediated diseases in the immunocompromised host. Counseling patients about these conditions requires a thorough understanding of the epidemiology, natural history of HPV, transmission and infectivity, risk of malignancy, and the role of the host immune response in clearing HPV lesions. Part II will provide an updated review of available treatments, with a focus on recent advances and the challenges faced in successfully treating HPV lesions in immunocompromised patients.

State of teledermatology programs in the United States

BACKGROUND Teledermatology programs in the United States have evolved over the past several decades. No systematic survey of teledermatology programs in the United States is available in peer-reviewed literature. OBJECTIVE To provide up-to-date information regarding the state of teledermatology programs in the United States. METHODS Active U.S. teledermatology programs were surveyed in 2011 with regards to practice models, clinical volume, and payment methods. These findings were compared with those from 2003. RESULTS By January 2012, 37 teledermatology programs were active in the United States. Store-and-forward teledermatology was the most frequent delivery modality offered by 30 (81%) of the programs. The majority of the programs were based at academic institutions (49%), followed by Veterans Administration hospitals (27%), private practice (16%), and health maintenance organizations (HMOs) (8%). The majority of programs (67%) provided services to their home state only, whereas the rest also served additional U.S. states or abroad. The median number of consultations per program was 309 (range, 5-6500) in 2011. The most frequent payer sources were private payers, followed by self-pay, Medicaid, Medicare, and HMOs. Since 2003, with the confirmed discontinuation of 24 previously active programs, the total number of active teledermatology programs in 2011 was 60% of that in 2003. However, the annual consult volume per program nearly doubled for the sustainable programs in 2011. LIMITATIONS Itemized billing information was not uniformly available from all programs. CONCLUSION The turnover in teledermatology programs is relatively constant, with an increase in consult volume for sustainable programs. Store-and-forward is the dominant modality of delivery, while hybrid technology model is emerging.

The Reliability of Teledermatology to Triage Inpatient Dermatology Consultations

IMPORTANCE Many hospitals do not have inpatient dermatologic consultative services, and most have reduced availability of services during off-hours. Dermatologists based in outpatient settings can find it challenging to determine the urgency with which they need to evaluate inpatients when consultations are requested. Teledermatology may provide a valuable mechanism for dermatologists to triage inpatient consultations and increase efficiency, thereby expanding access to specialized care for hospitalized patients. OBJECTIVE To evaluate whether a store-and-forward teledermatology system is reliable for the initial triage of inpatient dermatology consultations. DESIGN, SETTING, AND PARTICIPANTS Prospective study of 50 consenting adult patients, hospitalized for any indication, for whom an inpatient dermatology consultation was requested between September 1, 2012, and April 31, 2013, at the Hospital of the University of Pennsylvania, an academic medical center. The participants were evaluated separately by both an in-person dermatologist and 2 independent teledermatologists. MAIN OUTCOMES AND MEASURES The primary study outcomes were the initial triage and decision to biopsy concordance between in-person and teledermatology evaluations. RESULTS Triage decisions were as follows: if the in-person dermatologist recommended the patient be seen the same day, the teledermatologist agreed in 90% of the consultations. If the in-person dermatologist recommended a biopsy, the teledermatologist agreed in 95% of cases on average. When the teledermatologist did not choose the same course of action, there was substantial diagnostic agreement between the teledermatologist and the in-person dermatologist. The Kendall τ rank correlation coefficients for initial triage concordance between the in-person dermatologist and teledermatologists were 0.41 and 0.48. The Cohen κ coefficients for decision to biopsy concordance were 0.35 and 0.61. The teledermatologists were able to triage 60% of consultations to be seen the next day or later. The teledermatologists were able to triage, on average, 10% of patients to be seen as outpatients after discharge. CONCLUSIONS AND RELEVANCE Teledermatology is reliable for the triage of inpatient dermatology consultations and has the potential to improve efficiency.

Acral myxoinflammatory fibroblastic sarcoma: case series and immunohistochemical analysis.

Background:  Acral myxoinflammatory fibroblastic sarcoma (AMFS) is a rare, low‐grade neoplasm most often occurring on the extremities of adults. It consists of mixed inflammatory infiltrates with nodules of epithelioid, spindled and bizarre‐appearing cells within a fibrosclerotic‐to‐myxoid stroma. AMFS frequently recurs, but only rarely metastasizes.

HIV positive patients in Botswana state that mobile teledermatology is an acceptable method for receiving dermatology care

There is a severe shortage of dermatologists in sub-Saharan Africa, with many areas having no dermatologists at all.[1] Furthermore, there is an increased prevalence of skin disease in HIV patients, with many conditions being unique to this population or more severe than in immunocompetent patients.[2] The presence of many of these conditions may affect HIV management.[3,4] Store-and-forward teledermatology offers a method for increasing access to skin specialists. Although many areas have limited computer connectivity, mobile phone networks are more accessible.[5, 9] Mobile teledermatology uses mobile phones to perform store-and-forward teledermatology consultations. Studies evaluating patient acceptability of conventional store-and-forward teledermatology have been conducted in various study populations.[6,7,8] However, it is unknown whether patients, particularly those infected with HIV in resource-limited settings such as southern Africa, find the use of mobile phones acceptable for collecting their health information and would be willing to receive skin care through this method. It is possible that patients with a socially stigmatizing condition such as HIV have additional privacy concerns or that they may feel concerned about transmission of sensitive information by mass telecommunication technologies. While several studies have evaluated patient acceptance of store-and-forward teledermatology in industrialized countries, we were unable to find any studies on patient acceptance in resource poor settings among patients with HIV.[8,9,10,11] We have investigated whether the use of mobile teledermatology technology in a resource-limited setting in Botswana was culturally acceptable to HIV positive patients. Survey We conducted a cross-sectional survey of adult patients with HIV and mucocutaneous complaints in Botswana. Survey questions were developed by physicians in Botswana and the US, and were vetted by dermatologists with clinical experience in Botswana for face and content validity. The survey questions were tested with HIV positive outpatients at the dermatology clinic at the Princess Marina Hospital in Gaborone, Botswana. The study was approved by the appropriate ethics committees and the Botswana Ministry of Health. The study was conducted in consecutively recruited HIV positive patients in Botswana. The patients were at least 18 years old and presented with a skin or mucosal complaint that had not been previously evaluated by a dermatologist. The patients were recruited from the medical and oncology wards, the dermatology clinic, and the Infectious Disease Care Centre at the Princess Marina Hospital; from the Independence Surgery Center, a private primary care clinic in Gaborone; and from the outpatient clinics and medical wards at Athlone Hospital in Lobatse over a 5-week period from August 2009. Enrolled patients received both a face-to-face and mobile teledermatology evaluation and were afterwards asked to complete a questionnaire on their attitudes to mobile teledermatology at the end of the doctor-patient encounter. A Setswana-speaking nurse obtained consent, clarified any patient questions and administered the questionnaire in Setswana to patients unable to read English. Patients who were comfortable reading and writing in English completed the questionnaire on their own if they chose to do so. Enrolled patients received 30 pula (US

Exophiala spinifera as a Cause of Cutaneous Phaeohyphomycosis: Case Study and Review of the Literature

4.5) compensation to cover the cost of their travel. We screened 89 patients, of whom 77 (87%) were recruited and 75 completed the survey (97% completion rate), see Table 1. Two patients agreed to participate but could not complete the survey due to nausea from chemotherapy. Most patients (71%) were 31–50 years old. Thirty four (44%) were males. Most patients were single (71%). A significant proportion of patients was unemployed (44%) or received their regular skin care outside Gaborone (39%). The majority of patients stated that time (76%), costs (57%) and distance (41%) were the major barriers in seeking medical care for their skin conditions (Table 2). Forty five percent of patients stated that it took 1–3 h to see a skin specialist, while 53% of patients stated that it took more than 3 h. If privacy was guaranteed, 99% of patients reported that they would be completely comfortable with a mobile teledermatology consultation, while only one patient stated that he or she would have to think about it, and none stated that they would be uncomfortable. When asked what their greatest concern was regarding mobile phone skin consultations, 82% of patients reported none, while 8% reported concerns over not having a face-to-face interaction with the physician and an equal number (n=6) reported concerns over an incomplete representation of their skin or poor photograph quality (Table 2). The majority of patients (91%) believed that they would receive the same treatment and quality of care via mobile teledermatology consultation as with a face-to-face interaction. Most patients were willing to wait 1–3 days (40%) or up to one week (27%) to receive a response from the mobile teledermatology consultation in exchange for the convenience of not having to travel to see a skin specialist. When asked which body sites patients were willing to accept having a mobile teledermatology consultation for, 58% of patients said that photography of the face was acceptable, 97% accepted photography of the chest, 92% accepted photography of the genitals, 96% accepted photographs of the legs and 95% accepted photography of the body as a whole. There was a significant difference between the acceptability of mobile consultation for lesions on the face versus all the other body sites (all P-values<0.01). There was no significant difference for any body site by age or sex (P=0.15–0.75). Most patients cited reduced cost of travel (85%) and reduced time away from home or work (65%) as the benefits that would make them prefer mobile teledermatology consultations over face-to-face consultations, while 13% of patients stated that they would not prefer mobile teledermatology consultations over face-to-face interaction with a dermatologist. Table 1 Characteristics of the study population Table 2 Barriers to dermatology care and attitudes towards mobile teledermatology Our results provide insight into the demographics of the adult HIV positive population seen by the dermatology service in Gaborone and surrounding areas. A greater proportion of our patients (56%) were female, which reflects the national gender disparity in the prevalence of HIV. The median age of our cohort was 39 years, which is consistent with the age of peak prevalence of HIV nationally. Unlike national estimates however, most of our patients were single (71%), whereas the national HIV prevalence is highest in those who are widowed (40%).[12] In the context of a severe shortage of dermatology providers in Botswana, our results emphasise the difficulties these patients often encounter in obtaining dermatology care, including distance, cost and time as barriers to care. Furthermore, patients viewed mobile teledermatology as an acceptable alternative to obtaining skin care from a face-to-face consultation with a dermatologist. Our study had several limitations. The survey questions were not extensively validated. The questions were vetted by several dermatologists and other physicians and epidemiologists who all agreed on the importance of the inclusion of each question, which provides our instrument with some measure of content validity. The questions covered the dimensions recommended by Demiris et al. in their systematic review of patient acceptability studies in teledermatology.[8] Another limitation was the generalizability of our findings, since the results were obtained in HIV-positive adult patients in Botswana. However, it is reassuring to note that our cohort of patients was fairly representative of the general HIV-positive population in Botswana in terms of age and gender distributions. Finally, our patients were given compensation to help defray transportation costs, which may have led to response bias. However, such compensation is common in many studies. Overall, mobile teledermatology consultations were well accepted by HIV-positive patients with mucocutaneous conditions in Botswana. Most patients said that mobile teledermatology consultations for all parts of their body would be acceptable. Patients were most sensitive about the transmission of facial lesions through mobile teledermatology. However, even patients who cited concerns about the transmission of identifiable facial photographs consented to mobile teledermatology evaluations of facial lesions, so long as care was taken to minimize the possibility of recognition. Previous studies have assessed patient satisfaction with traditional store-and-forward teleconsultation in remote settings. [13] To our knowledge, this is the first study to address patient acceptance of mobile teledermatology in a population with a potentially stigmatizing underlying illness such as HIV. Given the rapid growth of mobile phone networks in developing countries, mobile teledermatology may be increasingly used to provide skin care in underserved communities. Our study demonstrates that HIV-positive patients find this technology acceptable for specialist consultations when face-to-face consultations may be difficult to obtain.

The role of dermatopathology in conjunction with teledermatology in resource-limited settings: lessons from the African Teledermatology Project

Exophiala spinifera has been reported as an agent of cutaneous disease 18 times in the literature. Clinical presentations of cutaneous lesions vary widely, including erythematous papules, verrucous plaques, and deep subcutaneous abscesses. The clinical distribution and course of disease are also variable, depending on the age and immune competency of the patient. Histologic appearance occurs in one of two patterns--phaeohyphomycosis or chromoblastomycosis. While E. spinifera appears to be susceptible to multiple antimicrobial agents in vitro, clinical experience with treatment modalities has been variable. Prior to the availability of sequencing methods, species identification was based on the histopathologic presentation in tissue and morphologic features of the fungus in culture. It is likely that E. spinifera cutaneous infections have been underreported due to its incorrect identification based on earlier methods. We report an additional case of E. spinifera phaeohyphomycosis, the first to be definitively identified by sequencing. In addition, we summarize the variable clinical, histopathologic, and morphologic features, as well as treatment responses described in previously reported cutaneous infections caused by E. spinifera.

Evaluation of cats as the source of endemic sporotrichosis in Peru

Background  Access to dermatology and dermatopathology services is scarce in sub‐Saharan Africa. Teledermatology provides consultations for healthcare providers in resource‐limited settings where specialty medical services are difficult to obtain, and the African Teledermatology Project has helped to bridge the gap in dermatological care in Africa. This program also allows for biopsy specimens to be sent to the USA for processing in cases where the clinical diagnosis is difficult and definitive diagnosis has implications for patient management. This study characterizes conditions diagnosed through clinicopathological correlation in conjunction with photos and tissue submitted to the African Teledermatology Project.

Mobile Teledermatology in Sub-Saharan Africa: A Useful Tool in Supporting Health Workers in Low-resource Centres

Although contact with domestic cats has been shown to be a risk factor for sporotrichosis in endemic areas, systematic evaluation of apparently unaffected cats as possible reservoirs for infection has not been explored. The goals of this study were to identify the following aspects of sporotrichosis in the endemic area of Abancay, Peru: (i) the overall prevalence of sporotrichosis in the cat population, (ii) the most common site where the fungus can be isolated from these cats, and (iii) whether cats without identifiable skin lesions may be carriers of the fungus in the oral mucosa, nasal mucosa, or nails. One household cat in each of 85 neighborhoods within the endemic area of Abancay, Peru was randomly selected. Oral and nasal swabs, as well as nail clippings were taken from 84 of the cats. In addition, samples from skin lesions that were suspected to be due to sporotrichosis were collected from cats or members of families that owned the pets. Cultures inoculated with two nasal swabs and one set of nail clippings from two different cats yielded Sporothrix schenckii, the identity of which were confirmed by rDNA sequencing. The overall prevalence of Sporothrix schenckii colonization was 2.38% (95% CI 0.41-9.14) in this cat population. None of the skin lesion samples from the cats and only one such sample from a family member were positive for Sporothrix schenckii in culture. These results suggest a role for domestic cats as a possible reservoir for sporotrichosis infection in Abancay.