whither teledermatology? why get a second opinion?

Whither Teledermatology?

Why get a second opinion?

Help with……..

Diagnosis

Management

Confirmation of same

Patient driven

Why Teledermatology?

Visual

Poor relation

Non urgent

Common


Long waiting times

Long distances

Accurate

Diagnosis (hard) v. Management (easy)

True consultation.


What’s needed?

Patient

Camera

Computer/e-mail

‘Normal’ medical skills

The referring doctor has to…

Take and transmit images/history

Enact advice received

How long……????

Traditional referral

Dear Jim, please see re skin.

Yours sincerely

Telemedicine and you…..

Work load increased

Responsibility increased

Time commitment increased


Educational opportunity

Financial opportunity?


Acquire new skills?

Wet wraps, dressings, dithranol, efudix, surgery, phototherapy, isotretinoin etc etc


Increased patient demand.

Dermatology patients expand to meet the number of dermatologists available.


“Don’t you think you should check with the teledermatologist?”


Fewer patients lost in ‘specialist land’


Medicolegal issues?

Who is responsible?

Where does the consultation take place?

Informed consent?

Privacy concerns?


Cost you or make you money??

Will you use it if it costs you money?

Telemedicine and you

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

Teledermatology and the patient…….

Rapid access

Decreased cost

No travel

?Equal service

Telemedicine and you

Should patients be able to directly access specialist telemedicine services?

Tele-Derm Consults

Examples of Cases Submitted to Jim

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, 15:58

" 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?

Jim’s Reply 21/10 17:47• 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

30/9, 14:07• Just after some input on this 3yo boy who

has a 1 month history of well demarcated skin lesions.

• 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?

Jim’s Reply 30/9, 16:04• 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.

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!

Jim’s 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!

Persistent Itchy Rash 10/10 11:38History:• 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

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

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

Jim’s Reply 10/10 13:47• 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.


• 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 perindopril

I will take some punch biospies and send you the results.

Do you think we should stop atorvostatin in the meantime ?

Thanks for your help

Jim’s 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


• 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

Jim’s 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.

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

Jim’s 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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whither teledermatology? why get a second opinion?

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