Mark Duffill

Patient cost-benefits of realtime teledermatology--a comparison of data from Northern Ireland and New Zealand.

As part of a randomized controlled trial of the costs and benefits of realtime teledermatology in comparison with conventional face-to-face appointments, patients were asked to complete a questionnaire at the end of their consultation. One hundred and nine patients took part in an initial teledermatology consultation and 94 in a face-to-face consultation. The proportion of patients followed up by the dermatologist was almost the same after teledermatology 24 as after a hospital appointment 26 and for similar reasons. Two hundred and three questionnaires were completed after the first visit and a further 20 after subsequent visits. Patients seen by teledermatology at their own health centre travelled an average of 12 km, whereas those who attended a conventional clinic travelled an average of 271 km. The telemedicine group spent an average of 51 min attending the appointment compared with 4.3 h for those seen at the hospital. The results of the present study, as in a similar study conducted in Northern Ireland, show that the economic benefits of teledermatology favour the patient rather than the health-care system.

Chloracne, palmoplantar keratoderma and localized scleroderma in a weed sprayer

The case of a 53‐year‐old man who developed chloracne, palmoplantar keratoderma and scleroderma after many years of exposure to a variety of chloracnegens is reported. Chloracne is a rare but important acneiform eruption associated with exposure to halogenated aromatic compounds used primarily in agriculture. However, to our knowledge, the association of palmoplantar keratoderma and scleroderma with exposure to chloracnegens has not been previously reported.

Pellagra, azathioprine and inflammatory bowel disease

Two patients are described who developed pellagra during treatment with azathioprine for inflammatory bowel disease.

Pseudochromhidrosis: Blue discolouration of the head and neck

A 57‐year‐old man is presented with blue pseudochromhidrosis affecting the face and neck following combination treatment with lansoprazole, a proton pump inhibitor, and ranitidine, a type two histamine receptor antagonist. The diagnosis was made on the basis of clinico‐histological features and growth of Malassezia furfur, and Bacillus species, not Bacillus cereus, in the absence of lipofuscin. The pseudochromhidrosis resolved on stopping both medications and did not recur on restarting only the proton pump inhibitor.

Teledermatology in the Waikato region of New Zealand

Teledermatology consultations over a video-link began at Health Waikato in 1995. Clinical trials involving about 500 patients have demonstrated the diagnostic accuracy and economic gains of these teleconsultations, and patient satisfaction with them. Yet, six years on, out-of-date equipment remains under-used. There has been no expansion of the network and no additional clinical teleconsultation services. Possible reasons include the excessive capital cost of videoconferencing equipment, clinician overwork, inconvenience, lack of reimbursement, administrative and governmental inertia, and little demand from patients and their doctors. To widen our referral base without the inconvenience of videoconferencing, we decided to offer a secure browser-based dermatology tele-advice service to referring general practitioners who owned digital cameras. With the increase in online health information and electronic communication, we assumed it would be popular. But, despite up to six-month waits for patients to be seen in the dermatology outpatient clinic, few patients have been referred to the service. Explanations have included time constraints, unavailability of a camera, no Internet access at the time of consultation and lack of reimbursement. Can we look forward to a future in which all doctors have high-speed access to the Internet at their desktop through their practice management systems? Who will pay? Will they continue to prefer conventional referral?

Melanoma--diagnosis by telemedicine.

The use of videoconferencing equipment for medical applications is undergoing evaluation in several centres in New Zealand. Health Waikato Ltd has chosen to examine the effectiveness of teledermatology clinics. A link has been established between the dermatology department at Waikato Hospital in Hamilton and Taumarunui Hospital, 100 miles (160 km) south. Taumarunui is a rural town with a population of about 10,000. It is located in the King Country, in the central part of North Island. The 23-bed hospital is staffed by a specialist physician and non-specialist medical practitioners. At the time the telemedicine link was established there was no specialist surgical service. Patients with skin diseases who live in Taumarunui must normally travel to visit a dermatologist in Hamilton. The journey takes 2.5 h each way by car. Those relying on public transport have only a single bus service each day, which returns at about 19:00. Videoconferencing units were installed at Taumarunui Hospital and Waikato Hospital in September 1995. Each unit (supplied by VTel, Australia) consisted of a monitor, a fixed camera (Canon VC-C1) with zoom capabilities (́ 8) and a coder/decoder (codec) (VTVideo, ver. 2.01). Communication between the systems was by way of ISDN lines at 128 kbit/s. During videoconferences, still images could be captured and stored for later viewing using software (Intel ProShare). InNovember 1995, the five local general practitioners serving Taumarunui were invited to refer patients with skin problems to the teledermatology clinic held at Taumarunui Hospital every two weeks. After giving informed consent, the patients took part in a consultation using the videoconferencing equipment. Each patient was accompanied in Taumarunui by the local specialist physician. The dermatology department of Health Waikato is participating in the UK Multicentre Teledermatology Trial run by the Institute of Telemedicine and Telecare at Queen’s University in Belfast. Consultations with patients in Taumarunui have been evaluated for phase III of these trials, which aims to evaluate the efficacy and economic viability of teledermatology. Fifty patients with a variety of diagnoses have been examined. They were offered face-to-face consultations at Waikato Hospital if they or the dermatologist felt this was necessary. If required, treatment was arranged locally or at Waikato Hospital. The value of the teledermatology service is illustrated by the following case, one of the first patients to consult the new service.

CYCLOSPORINE, AZATHIOPRINE AND LOCAL THERAPY FOR PYODERMA GANGRENOSUM

A markedly obese 54 year old woman with seropositive rheumatoid arthritis, anaemia, dyspepsia, controlled hypothroidism and depression presented with a seven month history of large pyoderma gangenosum ulcers on the shins. Routine dressings for the ulcers had been ineffective. Her arthritis was being treated with azathioprine and NSAIDs. Initial treatment with clobestasol proprionate and disodium cromoglycate under occlusion produced only partial healing. Introduction of Cyclosporin A and continuation of topical therapy, with the addition of triamcinolone acetonide injections, led to progressive healing which was complete after seven months. There has been no relapse to date. Cyclosporine can be combined with azathioprine and local therapy for successful treatment of pyoderma gangrenosum.

Multicentric reticulohistiocytosis in a child

A case of multicentric reticulohistiocytosis in an 8‐year‐old girl, which is a diagnosis rarely seen in children, is presented. Multicentric reticulohistiocytosis is a disorder of unknown aetiology, predominantly affecting the joints, skin and mucosa. Joint symptoms, but not cutaneous lesions, have improved with treatment with methotrexate.

Online consumer health education in dermatology.

Comprehensive and accurate health information for the consumer has the potential to improve patient care and health outcomes. NZDermNet, the web site of the New Zealand Dermatological Society, was established in 1996. Its consumer health information section includes more than 250 pages of information about skin diseases and their treatment. It has proven popular with health professionals and patients. In 2002 an average of more than 5000 visitors used the site daily.