Lara Ferrándiz

Economic evaluation of a store-and-forward teledermatology system for skin cancer patients:

We conducted an economic analysis of a store-and-forward teledermatology system for the routine triage of skin cancer patients. A cost-identification, cost-effectiveness and sensitivity analysis under a societal perspective was used to compare teledermatology with the conventional care alternative. In the period March 2004 to July 2005, a total of 2009 teledermatology referrals were managed from 12 Primary Care Centres (PCCs) of the public health system. The unit cost was of €79.78 per patient in teledermatology, and €129.37 per patient in conventional care (P < 0.005), with an incremental cost of €49.59 per patient in favour of teledermatology. The cost ratio between teledermatology and conventional care was 1.6. There was a significant inverse relation between the unit cost in each participating PCC and the number of teleconsultations transmitted from them (P < 0.001). Teledermatology resulted in a more cost-effective, or dominant, methodology. In a public health system equipped with an intranet, the routine use of teledermatology in skin cancer clinics is a cost-effective method of managing referrals.

Isolated Limb Perfusion for Malignant Melanoma: Systematic Review on Effectiveness and Safety

BACKGROUND Isolated limb perfusion (ILP) involves the administration of chemotherapy drugs directly into a limb involved by locoregional metastases. Unresectable locally advanced melanoma of the limbs represents one of the clinical settings in which ILP has demonstrated benefits. METHODS A systematic review of the literature on ILP for patients with unresectable locally advanced melanoma of the limbs was conducted. MEDLINE, EMBASE, and Cochrane database searches were conducted to identify studies fulfilling the following inclusion criteria: hyper- or normothermic ILP with melphalan with or without tumor necrosis factor (TNF) or other drugs providing valid data on clinical response, survival, or toxicity. To allocate levels of evidence and grades of recommendation the Scottish Intercollegiate Guidelines Network system was used. RESULTS Twenty-two studies including 2,018 ILPs were selected with a clear predominance of observational studies (90.90%) against experimental studies (9.10%). The median complete response rate to ILP was of 58.20%, with a median overall response rate of 90.35%. ILP with melphalan yielded a median complete response rate of 46.50%, against a 68.90% median complete response rate for melphalan plus TNF ILP. The median 5-year overall-survival rate was 36.50%, with a median overall survival interval of 36.70 months. The Wieberdink IV and V regional toxicity rates were 2.00% and 0.65%, respectively. CONCLUSIONS ILP is effective in achieving clinical responses in patients with unresectable locally advanced melanoma of the limbs. The disease-free and overall survival rates provided by ILP are acceptable. ILP is safe, with a low incidence of severe regional and systemic toxicity.

Effect of Teledermatology on the Prognosis of Patients With Cutaneous Melanoma

OBJECTIVE To evaluate differences in the initial prognosis of patients with cutaneous melanoma managed by teledermatology (TD) vs other non-TD referral systems. DESIGN Descriptive and longitudinal study of a store-and-forward TD system aimed at the triage of patients with suspicious pigmented lesions. SETTING In 2003, a store-and-forward TD triage system aimed at the selection of patients with skin growths suggestive of cancer was implemented at a skin cancer clinic. This system has been shown to be accurate and reliable and able to significantly shorten waiting periods for consultation with a dermatologist. PARTICIPANTS Patients with primary cutaneous melanoma referred to the Melanoma Clinic of the Dermatology Unit, Hospital Universitario Virgen Macarena, Seville, Spain, by TD or non-TD tracks were included in the study. MAIN OUTCOME MEASURES Decisions on the referral of patients with suspicious skin lesions by store-and-forward TD vs by a conventional referral system. Breslow thickness and tumor stage were recorded in each study group (TD and non-TD) and were compared. RESULTS Two hundred one patients with primary cutaneous melanoma were enrolled in the study. In total, 33.3% were managed at their primary care center by teleconsultation, whereas 66.7% were managed by a conventional referral system. The mean Breslow thickness was significantly lower among patients in the TD group than among patients in the non-TD group (1.06 vs 1.64 mm, P = .03). The frequency of melanoma with a favorable initial prognosis (tumor stages Tis and T1a) was significantly higher in the TD group (70.1% vs 56.9%, P = .03). The odds ratio of having a cutaneous melanoma with a favorable initial prognosis in the TD group was 1.96 (95% CI, 1.14-3.50; P = .04). CONCLUSION Teledermatology as a screening system for cutaneous melanoma has a favorable effect on the initial prognosis of patients with melanoma.

Alopecia frontal fibrosante. Valoración diagnóstica y terapéutica

Frontal fibrosing alopecia is a clinical entity characterized by recession of the frontotemporal hairline in middle-aged and older women. Since it was first described in 1994, more than 100 cases have been reported describing other clinical manifestations such as eyebrow and axillary alopecia, and perifollicular inflammation that help in the diagnosis of the disease and the differential diagnosis with other scarring alopecias. Histopathology reveals an inflammatory infiltrate and perifollicular lamellar fibrosis. Although numerous therapeutic options have been tested, including corticosteroids, finasteride, and minoxidil, none have shown clear benefits in terms of halting the progression of the alopecia.

Teledermatoscopy as a triage system for pigmented lesions: a pilot study

Background.  Skin‐cancer screening should rely on simple, low‐cost and high‐sensitivity diagnostic procedures.

Diagnostic and Therapeutic Assessment of Frontal Fibrosing Alopecia

Frontal fibrosing alopecia is a clinical entity characterized by recession of the frontotemporal hairline in middle-aged and older women. Since it was first described in 1994, more than 100 cases have been reported describing other clinical manifestations such as eyebrow and axillary alopecia, and perifollicular inflammation that help in the diagnosis of the disease and the differential diagnosis with other scarring alopecias. Histopathology reveals an inflammatory infiltrate and perifollicular lamellar fibrosis. Although numerous therapeutic options have been tested, including corticosteroids, finasteride, and minoxidil, none have shown clear benefits in terms of halting the progression of the alopecia.

An Economic Analysis of Presurgical Teledermatology in Patients with Nonmelanoma Skin Cancer

INTRODUCTION In patients with nonmelanoma skin cancer, store-and-forward teledermatology allows satisfactory diagnosis and surgical planning, thus shortening waiting lists and reducing travel requirements for patients in special situations. OBJECTIVE The aim of this study was to undertake an economic analysis of presurgical teledermatology, comparing it with a conventional health care approach. MATERIAL AND METHODS The cost and cost-effectiveness of presurgical teledermatology were analyzed from a societal perspective in the setting of a public hospital with a corporate intranet. The mean delay in surgery was used to measure effectiveness. Over a 12-month period, teledermatology was used in 134 patients with nonmelanoma skin cancer. The unit cost of each intervention (teledermatology and conventional health care approach), the cost ratio between the most and least expensive alternative, and the incremental cost-effectiveness ratio were calculated. We distinguished between 2 groups of patients: those with and those without physical impediments for travel. RESULTS The unit cost of the patients in whom teledermatology was used was euro 156.40 compared to euro 278.42 per patient in the conventional system; the conventional system was therefore 1.78 times more expensive than presurgical teledermatology. Teledermatology was more cost-effective, with an incremental cost-effectiveness ratio of euro 3.10 per patient and per day of delay avoided in patients without impediments for travel and euro 4.87 in those with impediments for travel. CONCLUSION Teledermatology used for remote presurgical planning and preparation in patients with nonmelanoma skin cancer is more cost-effective than the conventional referral system in a health setting with a communication network available.

Internet-based skin cancer screening using clinical images alone or in conjunction with dermoscopic images: A randomized teledermoscopy trial

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 (nCTC = 226, nclinical with dermoscopic teleconsultation = 228). 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.

Elephantiasis nostras verrucosa treated with surgical débridement.

© 2005 by the American Society for Dermatologic Surgery, Inc. • Published by BC Decker Inc ISSN: 1076–0512 • Dermatol Surg 2005;31:731. To the Editor: In June 2004, Iwao and colleagues reported in this journal a case of elephantiasis nostras verrucosa (ENV) that was successfully treated with surgical débridement.1 Management of this condition is challenging because few therapeutic options achieve good functional and cosmetic results. A 65-year-old woman with a 30-year history of ENV involving both lower legs was attended at our department. Examination of the left lower leg revealed a brown-colored edema entirely covered with multiple nodular and verrucous lesions, giving a cobblestone-like appearance to the skin from the maleolus to the knee (Figure 1A). Microbiologic studies ruled out a filarial infection. Under spinal anesthesia and sedation, we proceeded to shave (surgical blade no. 20) the nodules and verrucous lesions until an even surface was achieved (Figure 1B). Hemostasia of the bloody surface was obtained by means of conventional monopolar electrocoagulation. For postsurgical care, topical fusidic acid was applied under occlusion, and oral amoxicillin-clavulanic acid (500 mg/125 mg three times daily), subcutaneous heparin, and analgesic and anti-inflammatory drugs were also given. Dressings were changed on a daily basis, and the involved extremity was maintained elevated until complete reepithelialization of the wound could be observed 2 weeks after the patient was operated on (Figure 1C). After 1 year of follow-up, functional and subjective cosmetic results were acceptable. However, small nodules became apparent because the patient refused any sort of physiotherapy (Figure 1D). To the best of our knowledge, we report another example of ENV successfully treated by surgical débridement.

Diffuse neonatal hemangiomatosis with partial response to propranolol

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