Whither Teledermatology?

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Whither Teledermatology?
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Why get a second opinion?
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Help with..

• Diagnosis
• Management
• Confirmation of same
• Patient driven

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Why Teledermatology?

• Visual
• Poor relation
• Non urgent
• Common

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Why Teledermatology?

• Long waiting times
• Long distances
• Accurate
• Diagnosis (hard) v. Management (easy)

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Why Teledermatology?

• True consultation.

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Whats needed?

• Patient
• Camera
• Computer/e-mail
• Normal medical skills

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The referring doctor has to

• Take and transmit images/history
• Enact advice received
• How long????

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Traditional referral

• Dear Jim, please see re skin.
• Yours sincerely

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Telemedicine and you..

• Work load increased
• Responsibility increased
• Time commitment increased

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Telemedicine and you..

• Educational opportunity
• Financial opportunity?

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Telemedicine and you..

• Acquire new skills?
• Wet wraps, dressings, dithranol, efudix, surgery,
  phototherapy, isotretinoin etc etc

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Telemedicine and you..

• Increased patient demand.
• Dermatology patients expand to meet the number of
  dermatologists available.

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Telemedicine and you..

• Dont you think you should check with the
  teledermatologist?

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Telemedicine and you..

• Fewer patients lost in specialist land

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Telemedicine and you..

• Medicolegal issues?
• Who is responsible?
• Where does the consultation take place?
• Informed consent?
• Privacy concerns?

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Telemedicine and you..

• Cost you or make you money??
• Will you use it if it costs you money?

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Telemedicine and you

• Should the existence of telemedicine services
  be advertised to the general public if they can
  only access them through a doctor?

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Teledermatology and the patient.

• Rapid access
• Decreased cost
• No travel
• ?Equal service

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Telemedicine and you

• Should patients be able to directly access
  specialist telemedicine services?

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Tele-Derm Consults

• Examples of Cases Submitted to Jim

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Flaky Rash Face and Arm

• I submit this case on behalf of a colleague who
  has no access to the internet at the remote
  location. 21/10, 1558

" a 42 year old indigenous lady from Groote
Eyland (NT)who presents at Lockhart River (Qld)
with a one year history of these raised flaky
lesions which started around the lips, now has
spread to nose and cheek with some lesions
starting on the left upper arm. A biopsy was
reported as "non specific inflammation"
only." What is this?
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Jims Reply 21/10 1747

• This should be discoid lupus. The lip is pretty
  classic a diagnosis I missed on an aboriginal
  woman in Mossman in 1986.Ask the lab to review
  the histology with that diagnosis in mind.If no
  luck with path review repeat biopsy from non
  ulcerated skin.Do ANA/ENA etc for SLE and work
  up for plaquenil. Sun protection and potent
  topical steroids will help but need diagnosis
  first. See case 400 and 344 for much less severe
  examples.To be complete I'd throw leprosy and
  nasty tinea into differential but if this isn't
  lupus I will return to my singing career!jim

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30/9, 1407

• Just after some input on this 3yo boy who has a 1
  month history of well demarcated skin lesions.

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• These were initially treated with an antifungal
  cream which has had no effect.
• The lesions become more pronounced when exposed
  to the sun, appear dry, and have scaly skin on
  the peripheries of the lesions. They are on his
  cheeks, neck, and anterior torso.
• The child is otherwise well. I am considering
  psoriasis or discoid eczema and have a prescribed
  a few days of a moisturiser to see if this has
  effect.
• Would lupus present like this?

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Jims Reply 30/9, 1604

• They look eczematous to me. Probably endogenous
  dermatitis i.e. atopic.Ask re history of
  same.in an adult on those snaps I would have
  included mycosis fungoides and leprosy
  too!!Suggest fungal scrape, emollient and some
  steroid ointment. Use a potent one e.g.
  diprosone/elocon fo three or four days and then
  reduce to celestone M ointment not cream.Use
  1 hydrocortisone ointment on face.Review at 1
  week.Make sure they really push the
  moisturiser.Keep me posted.
• There is some post inflammatory hypopigmentation
  which explains the more prominence with sun
  possibly i.e. the non - affected skin darkens.
• Am in the wilds of NSW at the moment.

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Case Submitters Response

• Just to let you know that this child had a good
  response to the topical steroids with barely any
  lesions remaining. His mother will keep up with
  the skin moisturisers.Dx Eczema!

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Jims Response

• Good one!!It will probably recur but the
  emollients are vital.They need to try to
  minimise steroid use in the long term but not be
  afraid of it!

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Persistent Itchy Rash 10/10 1138

• History
• Started in groin and upper thighs and lower abdo
• Spread to chest arms hands lower legs
• Used pinetarsal some relief initially
• Using loafer on skin
• Using soap free wash
• Having 6 showers per day
• Used scabies treatment initially with no effect
• Ceased perindopril 6/52 ago
• Some improvement
• Has reoccurred again worse on lower abdomen
• Steroid creams used with no effect
• Phenergen making very drowsy so not using
• RAST -ve
• Had itchy rash for 3/12

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• Examination
• Scratch marks
• ? herald patch abdo
• Confluent areas on posterior elbows over
  scapula bilaterally
• Upper arms and lower abdo upper back worst
  areas
• Also web spaces and creases of wrists
• groin legs
• Red papules in clusters

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• Diagnosis
• Medications
• Aspirin 100mg Tablets 1 in the morning with food
• Atorvastatin calcium 20mg Tablets 1 at night
• Elocon 0.1 Cream apply daily
• Glucosamine sulfate 1000mg Capsules 1 in the
  morning with food
• Indapamide hemihydrate 1.5mg Tablet SR 1 in the
  morning
• Mobic 15mg Tablet 1 in the morning with food
• Norvasc 10mg Tablets 1 in the morning
• Phenergan Tablets 25mg Tablets 1 tab
• Tenormin 50mg Tablets 1 in the evening
• Plan
• Skin scarpings and send photos and story to
  telederm for further advice. Stop scratching
  using washer in shower to scratch. Restrict
  showers. cetaphil wash only. Moistuiser bd. Try
  non sedating anti-histamine. Avoid heat.
• Cessation of perindopril seemed to help initially
  but it has since gotten wrose while off
  perindopril. The rash as described is extensive
  and extremely itchy which I felt was not
  consistent with pityriasis. I performed a skin
  scraping which has come back negative on
  microscopy with culture pending.  I have attached
  some photos. Thank you for reviewing and advising
  on further investigation/ treatment.
• ? Pityriasis rosacea ? Drug reaction

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Jims Reply 10/10 1347

• On the images he has eczematous areas and also on
  the back some lesions of Grovers disease.Sudden
  onset like this think drug reaction and
  scabies.Ask re itchy penis/scrotum and look
  carefully for burrows especially between fingers.
  Ask if anyone at home itchy.Do a couple of 3 mm
  punch biopsies and let me know the results.If
  no evidence of scabies and after biopsies done
  start on Elocon ointment not cream b.d. with
  wet wrap occlusion applied for half an hour after
  a shower.Let me know the histology.We then
  may have to start stopping medications. See if
  you can work out what was most recently started
  and ensure list is complete i.e. no hidden
  drugs.If find evidence of scabies need whole
  household treated with Lyclear.Let me know
  results.

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Case Submitters Response

• Scabies was certainly high on the list initially
  particularly given the appearance of the hands
  (see photos). He and his partner (who has no
  symptoms) were both treated with Permethrin with
  no improvement.He has been taking Atorvostatin
  for many yearsThe rash has gotten worse since
  cessation of perindoprilI will take some punch
  biospies and send you the results.Do you think
  we should stop atorvostatin in the meantime
  ?Thanks for your help

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Jims Reply

• No wait and see.Scabies is a classic thing to
  fail treatment.If he has itchy bits on his
  genitals it is proabbaly scabies so ask and
  look!See case 111

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Case Submitters Response

• He did indeed have genital itch rash early on.
  I have asked him to retreat with Lyclear and his
  partner will also be treated. Will he need to
  repeat the treatment after 1/52 ?The biopsy
  result is pending

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Jims Reply

• No point half doing it. Repeat treatment is to
  kill the recently emerged babies after hatching
  but before they breed.Will be interested to
  hear how he fares.

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Case Submitters Response 21/10

• I received a lovely bunch of flowers today and a
  request to thank you also from a very relived man
  who can sleep again ! He had an improvement by
  1/7 post Lyclear which he interestingly did not
  get with the first treatment. The rash has
  improved dramatically already. Interestingly I
  had a phone call from the pathologists today
  asking if the rash could be syphilus prior to
  reviewing the patient later today. Thanks again

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Jims Reply

• Very interesting!If they fail to improve and it
  is scabies there are a lot of possible reasons
  reinfestation, secondary eczema, irritation from
  the treatment, scabetic nodules, post scabetic
  itch etc.Why did they wonder about syphilis?

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SETS

• SKIN
• EMERGENCY
• TELEMEDICINE
• SERVICE

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