Leonard Witkamp

A systematic review of five systemic treatments for severe psoriasis

We systematically reviewed the evidence concerning the ability of five systemic treatments to induce remission in patients with severe psoriasis: ultraviolet B (UVB), photochemotherapy (PUVA), methotrexate (MTX), retinoids (RET) and cyclosporin A (CYA). An elaborate literature search was performed, the validity of studies was assessed, and data were analysed. In total, 89, 193, 101, 155 and 127 studies (n=665) concerning UVB, PUVA, MTX, RET and CYA were found. The exclusion rate was high, mainly because of concomitant antipsoriatic therapy, outdated dosages or inadequate documentation. No study on MTX could be included. A total of 129 patient series was included in the analysis, reporting on 13,677 patients, Study size‐weighted averages of the proportions of patients with clearance and good, moderate and poor response (defined, respectively, as 95–100%, 75–100% and 50–75% and <50% reduction in the outcome measurements as compared with baseline) were calculated. PUVA therapy was associated with the highest average proportion of patients with clearance (70%) and the highest proportion of patients with good response (83%), followed by UVB (68%) and CYA (64%). Incidence of side‐effects per week was highest in the RET group and lowest in the phototherapy groups. This review may provide a basis for the development of guidelines for the treatment of psoriasis. Trials comparing oral modalities applied according to currently accepted standards should also be carried out.

Potential effect of patient-assisted teledermatology on outpatient referral rates

We carried out a pilot study on the feasibility and accuracy of store-and-forward teledermatology based on patient-provided images and history as a triage tool for outpatient consultation. Patients referred by their general practitioner provided a history and images via the Internet. The information was reviewed by one of 12 teledermatologists and the patient then visited a different dermatologist in person within two days. Three independent dermatologists compared the remote and in-person diagnoses in random order to determine diagnostic agreement. Broader agreement was also measured, by comparing the main disease groups into which the two diagnoses fell. The teledermatologists indicated whether an in-person consultation or further investigations were necessary. There were 105 eligible patients, aged four months to 72 years, who were willing to participate. For the 96 cases included in the analysis, complete diagnostic agreement was found in 41% (n= 39), partial diagnostic agreement in 10% (n= 10) and no agreement in 49% (n= 47). There was disease group agreement in 66% of cases (n= 63). Nearly a quarter (23%) of participating patients could have safely been managed without an in-person visit to a dermatologist.

Tertiary Teledermatology: A Systematic Review

Telemedicine is becoming widely used in healthcare. Dermatology, because of its visual character, is especially suitable for telemedicine applications. Most common is teledermatology between general practitioners and dermatologists (secondary teledermatology). Another form of the teledermatology process is communication among dermatologists (tertiary teledermatology). The objective of this systematic review is to give an overview of studies on tertiary teledermatology with emphasis on the categories of use. A systematic literature search on tertiary teledermatology studies used all databases of the Cochrane Library, MEDLINE (1966-November 2007) and EMBASE (1980-November 2007). Categories of use were identified for all included articles and the modalities of tertiary teledermatology were extracted, together with technology, the setting the outcome measures, and their results. The search resulted in 1,377 publications, of which 11 were included. Four categories of use were found: getting an expert opinion from a specialized, often academic dermatologist (6/11); resident training (2/11); continuing medical education (4/11); and second opinion from a nonspecialized dermatologist (2/11). Three modalities were found: a teledermatology consultation application (7/11), a Web site (2/11), and an e-mail list (1/11). The majority (7/11) used store-and-forward, and 3/11 used store-and-forward and real-time. Outcome measures mentioned were learning effect (6), costs (5), diagnostic accuracy (1), validity (2) and reliability (2), patient and physician satisfaction (1), and efficiency improvement (3). Tertiary teledermatologys main category of use is getting an expert opinion from a specialized, often academic dermatologist. Tertiary teledermatology research is still in early development. Future research should focus on identifying the scale of tertiary teledermatology and on what modality of teledermatology is most suited for what purpose in communication among dermatologists.

Accuracy and reliability of teledermatoscopy with images taken by general practitioners during everyday practice

We assessed the accuracy and reliability of teledermatoscopy with images taken by a general practitioner (GP) compared to face-to-face dermatological examination. GPs selected patients for teledermatoscopy and took both macro and dermatoscopic photographs. Patients were then referred to the local dermatologist for face-to-face examination. Accuracy and inter-observer reliability were calculated for the diagnosis and management plan. Image quality was rated by two observers on a three-point scale. A total of 108 teledermatoscopy consultations sent by 13 GPs were assessed by four dermatologists. Agreement was 0.61 (kappa) on diagnostic group and 0.23 on management plan. The inter-observer reliability was 0.65 on diagnostic group and 0.36 on management plan. The image quality was reported as bad in 36% of cases, reasonable in 28% and good in 36%. Agreement for cases with good quality images was 0.66 on diagnostic group and 0.42 on management plan. Teledermatoscopy in general practice had overall a lower accuracy and reliability than face-to-face consultation. In cases where a good quality image was reported, the accuracy increased, which emphasises that teledermatoscopy is highly dependent on a good quality images.

Efficacy and tolerability of multiple-dose SDZ IMM 125 in patients with severe psoriasis

Although cyclosporin is effective in immunosuppression following organ transplantation and in the treatment of psoriasis, its use is limited by its side‐effects, notably impaired renal function and hypertension. As SDZ IMM 125, a new derivative of the cyclosporin family, showed considerable immunosuppressive activity in experimental studies, with less effect on renal function, it was considered a potential successor to cyclosporin for both indications. In this multicentre, double‐blind, placebo‐controlled study, the efficacy and tolerability of 40, 100, 200 and 400mg SDZ IMM 125 daily were studied in 59 patients with psoriasis. Patients were followed for a period of 5 weeks (4 weeks treatment, and 1 week post‐treatment observation). A dose‐dependent effect of SDZ IMM 125 was observed. A significant correlation was found between the dose of SDZ IMM 125 and changes in the sum of severity scores of three indicator plaques. There was a significant decrease in the body surface area affected by psoriasis in the 400‐mg group (P < 0.01), whereas a decrease of the global psoriasis severity was observed in the 200‐mg (P < 0.01) and the 400‐mg groups (P < 0.001). No serious adverse events occurred during the 4 weeks of treatment. Three patients discontinued treatment because of adverse events (one sore throat, two influenza). Clinical adverse events were similar to those reported with cyclosporin, the most frequent being gastrointestinal disturbances. Estimation of renal function indices showed that increases from baseline values were dose dependent, and appeared to be similar to those seen with cyclosporin. Changes in liver function tests showed a clearcut dose‐dependent increase of some liver enzymes, principally alanine aminotransferase (ALAT). SDZ IMM 125 is effective in clearing psoriasis. However, long‐term studies comparing the efficacy and safety of SDZ IMM 125 and cyclosporin must be performed, to determine whether SDZ IMM 125 has a better risk‐benefit ratio than cyclosporin.

A pilot study on tertiary teledermatology: feasibility and acceptance of telecommunication among dermatologists

Tertiary teledermatology (TTD), where a general dermatologist consults a specialized dermatologist on difficult cases, is a relatively new telemedicine service. We evaluated TTD in a Dutch university hospital, where 13 general dermatologists used TTD to consult 11 specialized dermatologists and two residents at the university medical centre. We measured the avoided referrals to the university centre, the usability of the system and the user acceptance of it. During a three-month study, general dermatologists consulted via TTD 28 times. In 17 of the consultations (61%), the general dermatologists would have referred their patients to the university centre if teledermatology had not been available. Referral was not necessary after teledermatology for 12 of these 17 consultations (71%). The mean usability score (0–100) of all the users was 80. All dermatologists were satisfied with TTD (mean satisfaction of 7.6 on a 10-point scale) and acceptance was high. The baseline measurements showed that half of tertiary referrals were suitable for TTD. These results suggest that TTD reduces unnecessary physical referrals and that users are satisfied with it. A large-scale evaluation is now required.

Evaluation of a Tertiary Teledermatology Service Between Peripheral and Academic Dermatologists in The Netherlands

BACKGROUND Tertiary teledermatology (TTD)-secondary-care to tertiary-care teleconsultation-is applied rarely compared with the frequently applied secondary teledermatology (primary to secondary care). The objective of this study was to determine the effect of TTD on referrals from peripheral dermatologists to the tertiary center and to evaluate acceptance of TTD. MATERIALS AND METHODS From May 2010 to May 2012, 39 dermatologists could send in teleconsultations to one of two tertiary centers. Physical referrals to the tertiary centers prevented by TTD were calculated based on questions before and after TTD. The acceptance of the TTD system was evaluated through questionnaires, a focus group meeting, and personal interviews. RESULTS Eighty-five teleconsultations were sent by 13 peripheral dermatologists from nine care institutions and answered by 8 tertiary dermatologists. Of the patients, 62% (n=53) would have been referred physically to the tertiary center if teledermatology were not available. In this group, teledermatology prevented 81% (n=43) of physical referrals. Dermatologists indicated that TTD had important advantages such as fast response time, formalized records, and data and privacy security. However, the current work process using telephone and e-mail was preferred because of its ease of use and direct personal network. The following conditions that could lead to successful implementation were indicated: (1) a national TTD system including all dermatologists indexed according their subspecialty, (2) ability to send the TTD consultation to a dermatologist personally, (3) ability to discuss a case with multiple dermatologists, (4) connections to electronic health records, and (5) change in policies of tertiary centers or health insurers, where they would stimulate the use of TTD consultation for all referrals and questions. CONCLUSIONS Although quantitative results indicate that TTD can be used to improve triage between secondary and tertiary centers and dermatologists perceived advantages of TTD, the motivation to use TTD in this setting was lacking as current work processes were easier to use.

Automatic differentiation of color fundus images containing drusen or exudates using a contextual spatial pyramid approach.

We developed an automatic system to identify and differentiate color fundus images containing no lesions, drusen or exudates. Drusen and exudates are lesions with a bright appearance, associated with age-related macular degeneration and diabetic retinopathy, respectively. The system consists of three lesion detectors operating at pixel-level, combining their outputs using spatial pooling and classification with a random forest classifier. System performance was compared with ratings of two independent human observers using human-expert annotations as reference. Kappa agreements of 0.89, 0.97 and 0.92 and accuracies of 0.93, 0.98 and 0.95 were obtained for the system and observers, respectively.

Health Management Practice as a Method to Introduce Teledermatology: Experiences from the Netherlands

Because of increased demand, healthcare provision will come to a standstill if its efficiency is not changed rigorously. Telemedicine is a solution to increase healthcare efficiency. The Health Management Practice (HMP) model is a roadmap for developing, investigating and implementing telemedicine tools. Teledermatology after selection by the general practitioner has been fully integrated in the Netherlands. Teledermatology has led to higher satisfaction and learning effect, 75% reduction of all physical referrals to dermatologists, 20.6% cost savings and better quality of care. HMP has enabled KSYOS to perform over 50,000 teledermatology consultations, expand teledermatology to other EU countries, as well as to other areas such as teleophtalmology, telespirometry and telecardiology.

Telemedicine and Skin Cancer: Teledermatology and Teledermoscopy

Telemedicine is the delivery of healthcare and sharing of medical knowledge by use of information and communication technology (ICT), enabling caregivers and caretakers to work together independent of place and time for the purpose of consultation, remote medical procedures or examinations, and education (Strode et al., JAMA 281:1066–1068, 1999). Telemedicine has been thought as an organizational answer to keep healthcare accessible for the general population (Wurm et al. J Dtsch Dermatol Ges 6:106–112, 2008). Its benefits may be vital for the restructuring of healthcare systems in the Anglo-Saxon world and the progression towards better healthcare in developing countries in the coming decades. This chapter describes teledermatology (TD), the adaptation of telemedicine on the field of dermatology, the various TD implementations, the growing participation of TD in skin cancer care, and how not the technology but the whole telemedicine concept can be adopted as the advocate for change.