|Introduction to dermoscopy
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 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: