Stephen Shumack

Accuracy and reliability of store-and-forward teledermatology: preliminary results from the St George Teledermatology Project.

Teledermatology is the practice of dermatology across distances (and time) and involves the transfer of electronic information. To be effective and safe, the teledermatology process needs to demonstrate an acceptable level of accuracy and reliability. Accuracy is reflected by the degree of concordance (agreement) between the teledermatology and face‐to‐face diagnoses. Reliability is dependent on how consistently a set of results can be reproduced across different operators. Mean concordance (primary diagnoses) achieved by four dermatologists studying 53 store‐and‐forward diagnostic cases, originating from 49 referred patients, was 79% (range 73–85%). When the differential diagnoses were taken into account, the variation across individual dermatologists narrowed further, with a mean of 86% (range 83–89%). In contrast, the mean general practitioner (GP; n = 11) concordance (GP face‐to‐face vs reference dermatologist store‐and‐forward diagnoses) was 49%. An interim review of all 49 teledermatology patients showed no adverse outcome at the end of 3 months. The ability to request face‐to‐face visits by dermatologists, combined with GPs maintaining primary care of the referred patient, serve as additional safeguards for patients using a telemedicine system. Our results indicate that teledermatology management of referred skin complaints is both accurate and reliable.

Epidemiology and aetiology of basal cell carcinoma

Basal cell carcinoma is the most common malignancy among caucasians worldwide. Accurate epidemiological data can be difficult to obtain, but does suggest that the overall incidence is increasing. Risk factors include skin type, prior skin cancers and immunosuppression. Research in free radical‐mediated cellular injury and innate defence mechanisms, and ultraviolet radiation‐induced genetic mutations have improved our understanding of the development of this disorder.

Imaging the skin

Since the discovery of X‐rays, the use of imaging technology has continued to play an important role in medicine. Technological advancements have led to the development of various imaging modalities, most of which have been used to image organs deep within the human body. More recently, attention has focused on the application of imaging technology for evaluation of the skin. A variety of techniques are currently being used to examine the skin and these include specialized photography, surface microscopy, ultrasound, laser Doppler perfusion imaging, confocal microscopy, and magnetic resonance imaging. These modalities can provide information that can assist in the management of skin problems. Although many of these techniques are still undergoing research, they are showing promise as useful clinical tools in dermatology.

Assessing diagnostic skill in dermatology: A comparison between general practitioners and dermatologists

This retrospective study was conducted to assess and compare the diagnostic accuracy between referring general practitioners and dermatologists with regard to skin conditions. Six hundred and fifty‐six consecutive general practitioner referrals to a private dermatology practice and a dermatology outpatient department were assessed. The concordance rate in diagnoses from a wide spectrum of dermatological diseases was compared between general practitioners and dermatologists. Referring general practitioners agreed with dermatologists’ clinical diagnosis and histology (when available) in 42% of cases. The concordance between general practitioners and dermatologists in the setting of non‐biopsied cases is 45%. One hundred and fifty‐one of 656 (23%) conditions had histological confirmation. Overall, general practitioners agreed with the histological diagnosis in 24% of cases and dermatologists agreed with the histological diagnosis in 77% of cases.

Short‐course therapy with imiquimod 5% cream for solar keratoses: A randomized controlled trial

A dual‐centre, randomized, double‐blind, vehicle‐controlled study was conducted to evaluate the safety and efficacy of short courses of therapy with imiquimod 5% cream in clearing ≥75% of baseline solar keratoses (SK) within a field of treatment. Subjects with 5–15 baseline SK within one treatment area (scalp, forehead and temples, or both cheeks) were randomized to apply imiquimod or vehicle cream to the entire treatment area three times a week for 3 weeks. Subjects were assessed 4 weeks after completing the first course for clearance of lesions. Subjects with <75% clearance were commenced on a second 3‐week course of study cream. Subjects with ≥75% clearance were followed up until study completion without further therapy. All subjects were evaluated at the study endpoint of 14 weeks after initiating therapy for assessment of the primary outcome (≥75% clearance of baseline solar keratoses). Twenty‐one out of 29 (72%) imiquimod‐treated subjects cleared ≥75% of baseline lesions compared with 3/10 (30%) subjects using the vehicle cream (Fishers exact test, P = 0.027). Imiquimod was well tolerated. The present study has a short follow‐up endpoint, but suggests that imiquimod is a potential therapeutic alternative in patients with SK.

Summary of actinic keratosis studies with imiquimod 5% cream.

Imiquimod is being investigated as a therapeutic option for the management of actinic keratosis. Three recent clinical trials have demonstrated a reasonable efficacy rate and high safety profile. ‘Cycle’ therapy may improve the safety profile while maintaining efficacy. ‘Field’ treatment with imiquimod may uncover and treat ‘subclinical’ actinic keratoses, which in turn may potentially result in fewer recurrences. Longer follow‐up studies are required to investigate this possibility.

Australian teledermatology: The patient, the doctor and their government

Telemedicine is an emerging technology within Australia. We review the historical development of telemedicine and discuss the clinical and non‐clinical issues surrounding its practice in this country. Teledermatology is one application of telemedicine. We discuss the potential impact of teledermatology on patients, doctors and third parties such as government. So far, teledermatology has received little attention from Australian dermatologists. By contrast, the Government and other organizations are showing keen interest in establishing infrastructure within this country. We believe it is time for dermatologists to become more involved in the practice and politics of telemedicine within Australia.

Teledermatology: Influence of zoning and education on a clinician's ability to observe peripheral lesions

Teledermatology can benefit rural and remote communities, where specialist dermatological services may not be readily available. Regarding store‐and‐ forward teledermatology, we hypothesized that the site of a lesion in an image (zoning) may influence a clinicians ability to observe target lesions, and that education on image viewing may improve use of this technology. We examined this by conducting both pre‐ and post‐education studies. The education on image viewing consisted of a presentation on the outcome of the first study‐survey on image viewing. The first study demonstrated that zoning influences a clinicians visual attention and that significant, concurrent lesions in the periphery may be missed. The second study demonstrated that brief education could produce a measurable change in observing peripheral lesions. These findings have medico‐legal implications and suggest that further education in the use of such technology is necessary in order to optimize patient care and prevent potential errors.

Epidemiology and pathogenesis of scleroderma

Scleroderma is a heterogenous connective tissue disorder characterized by fibrosis of the skin, with or without internal organ involvement. The aetiology of scleroderma may involve both environmental and genetic factors. Abnormalities involving the immune system, vascular tissue and extracellular matrix have been demonstrated. Recent research has focused on microchimerism as a risk factor for the development of scleroderma. This article reviews the epidemiology and pathogenesis of this disorder.

Progress in Australian teledermatology.

Because of their remoteness, the majority of rural towns in Australia are disadvantaged in terms of access to dermatological services. Telemedicine offers one solution. Since the mid-1990s, Australian dermatologists have experimented with tele-medicine as an adjunct to clinical practice. The technical viability of teledermatology was first demonstrated in 1997. In 1999, the accuracy and reliability of teledermatology were demonstrated in a real-life urban setting. In 2001, Broken Hill (in western New South Wales), a location remote from dermatology services, served as a trial site for the institution of tele-dermatology as the primary method of accessing dermatological services. High patient and general practitioner acceptability and positive medical outcomes were demonstrated, but the study also revealed unexpected barriers and pitfalls in the effective operation of rural teledermatology.