TRIAGE

This photo is a recent case that was submitted to me. Notable features were the very dark pigmentation of these lesions and their irregular contours. They also appeared larger than most moles. The risk for a malignant melanoma was significant so we contacted the patient and had him in the office the next day for a biopsy. Fortunately, once in the office the pigment was not as dark as in the photo but one lesion was still suspicious so a biopsy was done. The pathology report revealed a benign nevus. This was a nice example of using teledermatology to get an expedited office visit and a biopsy.

Used with permission

OUTCOMES

The most recent issue of JAMA Dermatology had a study from a group at UC Davis that compared outcomes in patients with atopic dermatitis who were managed with regular office visits or online dermatology visits. In both groups there were significant improvements and the online patients did just as well as the patients who were seen in the office. What was notable is that this study was done in a rural area where patients travel large distances to see medical specialists. The travel burden for the online visitors was vastly less.

SPEED

I got this case on the weekend. The patient was able to get a photo that clearly showed these minute blisters grouped on a red area of skin. There also was a smaller group of blisters off to one side. These findings are consistent with shingles which is a reactivation of varicella-zoster virus. This is the virus that causes chicken pox. The important aspect here is that if a patient with shingles doesn’t receive treatment within 72 hours, the medication is ineffective and the person is subject to the potentially devastating effects of the virus. This patient was given valacyclovir within 24 hours of the initial outbreak and cleared without any problems.

Possible Shingles condition

DIAGNOSTIC ACCURACY

To formulate a diagnosis, the physician relies on both subjective evidence obtained by speaking with the patient and objective evidence gained by examining the patient. Historically this process required a face to face visit with the physician.

Photos transmitted over the internet now allow physicians to examine their patients from afar and render diagnoses and treatment recommendations without an office visit. This novel approach to healthcare prompted multiple studies that examined the diagnostic accuracy of these internet evaluations. The results showed good but not perfect correlation between internet diagnoses and face to face exams. However, even though the diagnoses were not always the same, there was almost always agreement on initial treatment or whether to biopsy a lesion.