Increasing subspecialization in medicine results in a concentration of experts in few medical centers and a lack of expert knowledge in other, predominantly rural areas. Physicians in these areas may have problems with the diagnosis and management of equivocal pigmented skin lesions. The patient has to be sent to an expert in a medical center for further diagnosis and, depending on the results, for adequate treatment. This transportation means inconvenience for the patient and costs for the medical care system due to re-examination by the expert. Finally, the whole procedure of patient transportation and re-examination that is cost- and time-consuming might have been unnecessary if the expert could have been consulted beforehand.

In the last few years the continuous progress in computer technology has lead to the introduction of a revolutionary diagnostic tool, known as telemedicine, that is improving communication between physicians and medical specialists and will help decrease costs for the citizen and the health care system. In several medical specialties, where digital images are crucial in diagnosis and management decisions, such as radiology or internal medicine (endoscopy; ultrasound) to name but a few, telemedicine already represents a well-integrated part of daily medical life. In addition, it has recently been shown that teledermatology is a useful and suitable diagnostic tool, especially in communities where dermatologists are not available [Kvedar 1997, Lesher 1998, Loane 1998, Lowitt 1998, Norton 1997, Perednia 1995, Phillips 1997, Zelickson 1997]. An even newer diagnostic approach is teledermoscopy that permits to send clinical as well as dermoscopic images of pigmented skin lesions using telematic networks [Piccolo 1999, Provost 1998].

Recently, Piccolo et al. performed a teledermoscopic study on 66 pigmented skin lesions by sending clinical and dermoscopic images from L’Aquila (Italy) to Graz (Austria) via internet (E-mail). The results of this study, achieved by the store-and-forward approach, demonstrated that the degree of concordance between “face-to-face” diagnosis and telediagnosis was 91% when performed by experts in dermoscopy on both sides [Piccolo 1999]. (See Table)

Another encouraging approach due to the fast and easy exchange of information via the internet is the possibility to discuss dermoscopic images with experts all over the world asynchronously. The New York University Group of Alfred W. Kopf along with Harold Rabinovitz set up an “e-Room” called Dermnetwork to share interesting dermoscopy cases. Each “room” can be “entered” only by those who have access (passwords) thus assuring confidentiality since patients are involved (http://www.dermnetwork.org).

In our estimation, teledermoscopy may contribute significantly to reduce waiting time and workload in dermatologic clinics, spare the patients unnecessary distress, and ultimately save public money whilst providing a faster, reliable and more efficient service.

Dermoscopic-pathologic correlation using telecommunication

The histopathologic diagnosis of a given pigmented skin tumor can be facilitated by the simultaneous assessment of the histologic specimen and the clinical and dermoscopic photographs of the very same lesion. Nowadays, using digital technology in conjunction with telecommunication, digital clinical and dermoscopic images of fairly good quality can be transmitted easily via the Internet to the dermatopathologist who is actually going to view the corresponding histologic specimen. 

The careful inspection of a dermoscopic image together with the corresponding specimen would then enable the dermatopathologist to decide whether all representative dermoscopic features are also present histopathologically. So, serial sections or additional sections from other blocks can be ordered when the underlying histopathologic structures of ELM features, clearly visible on the dermoscopic images, are not present in the histologic specimen. At the moment, however, no studies have been performed to critically evaluate the impact of this combined assessment on the accuracy of histopathologic diagnosis of melanocytic skin tumors.

In conclusion, dermoscopy should not be regarded simply as a magical tool for facilitating the diagnosis of pigmented skin lesions but also as a tool for in-vivo gross pathology. By viewing dermoscopic images in addition to a meticulous gross pathology protocol, relevant ELM features and their histopathologic correlates can be clearly identified. The significance of this method of clinicopathologic correlation in the field of pigmented skin lesions is twofold:

  1. Further standardization and refinement of ELM features can be accomplished only by having a real understanding of their histopathologic correlates, and

  2. the accuracy of histopathologic diagnosis, especially in equivocal cases, might be improved when a dermoscopic image of a given melanocytic tumor is provided together with the histologic specimen. So, linking dermoscopy more closely with cutaneous pathology may be of substantial help to both dermatologists and dermatopathologists.

 

Clinical and histopathologic data of 66 pigmented skin lesions
Age Median: 41.2 years; Range: 8-82 years
Sex Males:Females = 34:32

 

Location (No.)
  • back (24);
  • abdomen (8);
  • chest (4);
  • thorax (3);
  • head (2);
  • nose (1);
  • lower extremities (11);
  • buttocks (5);
  • upper extremities (3);
  • thigh (3);
  • neck (1);
  • ear (1)
Histopathologic Diagnosis (No.)
  • Clark nevus (50);
  • blue nevus (1);
  • Reed nevus (1);
  • melanoma (1);
  • angiokeratoma (1);
  • dermatofibroma (1);
  • tattoo (1)
  • Clark nevus + angioma (2);
  • dermal nevus (1);
  • Spitz nevus (1);
  • basal cell carcinoma (4);
  • epidermal cyst (1);
  • seborrheic keratosis (1);

 

Diagnostic concordance
Face-to-face L'Aquila versus telediagnosis Graz: 60/66 (91%)
Face-to-face L'Aquila vs histopathology: 61/66 (92%)
Telediagnosis Graz vs histopathology: 57/66 (86%)

 

Level of diagnostic difficulty
high 16 lesions (24%)
medium 35 lesions (53%)
low 15 lesions (23%)

 

Image quality
excellent 16 lesions (24%)
good 39 lesions (59%)
sufficient 11 lesions (17%)

 

References

  1. Kvedar JC, Edwards RA, Menn ER, Mofid M, Gonzalez E, Dover J, et al. The substitution of digital images for dermatologic physical examination. Arch Dermatol 1997;133:161-167.

  2. Lesher JL, Davis L, Gourdin FW, English D, Thompson WO. Telemedicine evaluation of cutaneous diseases: a blinded comparative study. J Am Acad Dermatol 1998;38:27-31.

  3. Loane MA, Korbett R, Bloomer SE, et al. Diagnostic accuracy and clinical management by real time teledermatology. Results from the Northern Ireland Arms of the UK Multicentre Teledermatology Trial. J Telemed Telecare 1998;4:95-100.

  4. Lowitt MH, Kessler II, Kauffman CL, Hooper FJ, Siegel E, Burnett JW. Teledermatology and in-person examinations. A comparison of patients and physician perceptions and diagnostic agreement. Arch Dermatol 1998;134:471-476.

  5. Norton SA, Burdick AE, Phillips CM, Berman B. Teledermatology and underserved populations. Arch Dermatol 1997;133:197-200.

  6. Perednia DA, Brown NA. Teledermatology: one application of telemedicine. Bull Med Libr Assoc 1995;83:42-47.

  7. Phillips CM, Burke WA, Shechter A, Stone D, Balch D, Gustke S. Reliability of dermatology teleconsultations with the use of teleconferencing technology. J Am Acad Dermatol 1997;37:398-402.

  8. Piccolo D, Smolle J, Wolf IH, Peris K, Hofmann-Wellenhof R, Dell’Eva G, Burroni M, Chimenti S, Kerl H, Soyer H.P. “Face-to-face” versus remote diagnosis of pigmented skin tumors: a teledermoscopic study. Arch Dermatol 1999; 135:1467-1471.

  9. Provost N, Kopf AW, Rabinovitz HS, Stolz W, De David M, Wasti Q, Bart RS. Comparison of conventional photographs and telephonically transmitted compressed digitized images of melanomas and dysplastic nevi. Dermatology 1998;196:299-304.

  10. Zelickson BD, Homan L. Teledermatology in the nursing home. Arch Dermatol 1997;133:171-174.