Teledermatología. Capacidad para reducir consultas presenciales según el grupo de enfermedad

IntroductionTeledermatology was initially considered useful and cost-effective, especially when distances to the reference hospital were significant. It is currently gaining importance as a more specific tool that can evaluate the need for a rapid referral or to decrease medical costs. The aim of this study was to assess the capacity of teledermatology for resolving cases in different groups of disease.Material and methodsTeleconsultations received in our Department of Dermatology between May 2011 and April 2014 were evaluated according to the virtual diagnosis, the indication given by the dermatologist who evaluated the teleconsultation (discharge/referral), reasons for attending to hospital, reasons for more than one virtual consultation, final face-to-face diagnosis, and diagnostic agreement between the virtual and face-to-face diagnoses.ResultsAn assessment was made on 1163 virtual consultations. Inflammatory diseases were the most frequent diagnosis group (45%). A total of 50.82% of virtual consultations were discharged. The highest resolution rate was achieved by the infectious diseases group, followed by inflammatory diseases (78.4% and 62.8%, respectively). Malignant lesions were referred in nearly all cases (96.7%). The main reason for a referral was the need for diagnostic confirmation or complementary studies (59.8% of all cases). A total of 102 patients received more than one teleconsultation, principally due to incomplete clinical data or poor-quality images. The agreement rate between virtual and face-to-face diagnosis was 88.95%.ConclusionTeledermatology avoids around 50% of the primary care referrals. The highest resolution rate is achieved in the infectious diseases group, followed by the inflammatory diseases group and, secondly, by benign tumours and benign melanocytic lesions.     

Teledermatology applied following patient selection by general practitioners in daily practice improves efficiency and quality of care at lower cost

Background Teledermatology, the application of telemedicine in the field of dermatology, has similar accuracy and reliability as physical dermatology. Teledermatology has been widely used in daily practice in the Netherlands since 2005 and is fully reimbursed. Objectives This study prospectively investigated the effect of teledermatology on efficiency, quality and costs of care when integrated in daily practice and applied following patient selection by the general practitioner (GP). Methods Teledermatology consultations between GP and regional dermatologist were performed in daily GP practice in the Netherlands. Efficiency of care was measured by the decrease in the number of physical referrals to the dermatologist. Quality of care was measured by the percentage of teleconsultations for second opinion, physical referrals resulting from these teleconsultations, the response time of the dermatologists and educational effect experienced by the GP. Costs of conventional healthcare without teledermatology were compared with costs with teledermatology. Results One thousand, eight hundred and twenty GPs and 166 dermatologists performed teledermatology, and 37 207 teleconsultations performed from March 2007 to September 2010 were included. In the group of patients where the GP used teleconsultation to prevent a referral (n = 26 596), 74% of physical referrals were prevented. In the group of patients where the GP used teleconsultation for a second opinion (n = 10 611), 16% were physically referred after teleconsultation. The prevented referral rate in the total population was 68%. The mean response time of dermatologists was 4·6 h (median 2·0). GPs indicated that there was a beneficial educational effect in 85% of the teleconsultations. The estimated cost reduction was 18%. Conclusions Teledermatology can lead to efficient care probably at lower cost. We are therefore of the opinion that teledermatology following GP selection should be considered as a possible pathway of referral to secondary care.     

An evaluation of the role of a store-and-forward teledermatology system in skin cancer diagnosis and management

There is currently much interest in the potential role of telemedicine in improving the delivery of dermatological care in the UK. The two teledermatology systems available at present are divided into live video and store-and-forward technology. We investigated the value of a store-and-forward teledermatology system in the diagnosis and management of lesions suspicious of skin cancer. A total of 163 store-and-forward referrals of patients with one lesion each were assessed independently by a Consultant and a third-year trainee dermatologist. The accuracy of diagnosis and appropriateness of management from these assessments was compared to a subsequent face-to-face consultation with the Consultant. Analysis of the Consultants' diagnoses showed that 48% were identical for teledermatology and conventional face-to-face consultations. A further 17% of teledermatology diagnoses included the actual clinical diagnosis as a possibility but 20% were either incorrect or a diagnosis could not be made. In the remaining 15% of cases the digital image was of insufficient quality for assessment. Of the trainee's reports, 44% were identical to the clinical diagnoses and another 20% included the clinical diagnosis as a possibility. The management plan was appropriate in 55% of the total teledermatology referrals assessed by the Consultants and in 52% assessed by the trainee when compared with the conventional consultation. This study illustrates that the store-and forward type telemedicine system has limited diagnostic accuracy for skin lesions. However, our results suggest that store-and-forward teledermatology may be suitable and safe for screening out clearly benign lesions but the study casts doubt on its efficiency.     

Review of teleconsultations for dermatologic diseases

BACKGROUND: Telemedicine has been increasingly used in some areas to provide consultation for isolated populations that might otherwise have difficulty accessing specialty care. Little information exists on what types of patients or diseases are being seen in dermatology telemedicine consultation services. OBJECTIVE: To review our consultations done over a regional telemedicine network with an emphasis on looking at what type of patient, cutaneous diseases, and diagnostic or therapeutic recommendations were made. RESULTS: Between August 1992 and December 1997, 796 teleconsultations were done. The most common diagnoses made were eczemas, follicular based diseases, skin infections, and skin tumours. Steroids were the most commonly recommended therapy, along with antibiotics, antihistamines, and antifungal therapy. Diagnostic recommendations commonly made were a skin biopsy and potassium hydroxide preparation. CONCLUSIONS: Common skin problems were seen by our dermatology teleconsultation service. A significant number of diagnostic biopsies and potassium hydroxide preparations were recommended. The efficacy of telemedicine in the delivery of dermatologic care is reviewed.     

Evaluating a telemedicine system to assist in the management of dermatology referrals

BACKGROUND: Teledermatology systems fall into two categories: live video or store-and-forward. In the former, video-conferencing equipment is used to connect a patient with a remote consultant. This method has been evaluated as an aid to dermatology, but it is expensive both in terms of capital and running costs. Video consultations are generally longer than conventional ones and harder to schedule. Some authors have considered store-and-forward as an alternative to live video: instead of a consultation, specialists could make a rapid inspection of a transmitted still image. OBJECTIVES: A study was conducted to evaluate the role of telemedicine in the dermatology outpatients department of a district general hospital (Whittington Hospital NHS Trust, London, U.K.). METHODS: One hundred and ninety-four patients were seen by one of two consultant dermatologists. A nurse used a video camera to store digital images of each patient's problem and compiled a history from the GP's referral letter. The images were reviewed 13 months later by both dermatologists; they recorded a provisional diagnosis and an assessment of how urgent an appointment would have been made given the information provided by the system. A third consultant graded the level of agreement between the telemedicine diagnoses and the face-to-face consultations. RESULTS: High levels of agreement were found between the diagnoses of the dermatologists using the system to inspect images and those of the dermatologist who saw the patients (77%). Consultants using the system recommended fewer urgent appointments (32% compared with 64%) and felt that in 31% of cases the patient did not need to be seen. In 15% of these cases (5% of the total), however, their diagnosis differed significantly from that of the consultant who saw the patient. Had the system been in use, 14% of patients conventionally assigned a non-urgent appointment would have been seen urgently. CONCLUSIONS: The images allowed a reasonably accurate diagnosis. The software was not reliable (six cases could not be viewed), or easy to use (it took approximately an hour to view 20 cases) but an improved version could be used in triaging outpatient appointments.     

Suspected skin malignancy: a comparison of diagnoses of family practitioners and dermatologists in 493 patients

BACKGROUND: In the Irish health system, dermatology patients present to their family practitioner for diagnosis and treatment, and are referred to a dermatologist for a second opinion where diagnosis is in doubt or when there has been therapeutic failure. The level of expertise in dermatology amongst family practitioners varies considerably. AIM: To compare the diagnoses of general practitioners and dermatologists over a selected period in patients with a possible diagnosis of skin cancer. METHODS: Four hundred and ninety-three patients were seen by one of two dermatologists over a 1-year period at a rapid referral clinic for patients suspected by their family practitioners of having unstable or possibly malignant skin lesions; 213 of these patients had a diagnosis made on clinical examination by the dermatologist, while 264 had diagnostic or therapeutic biopsies performed; 16 patients defaulted on surgery. RESULTS: The diagnoses of the family practitioners agreed with the diagnoses of the dermatologists on patients diagnosed clinically in 54% of cases. Thirty-eight patients had histologically proven skin malignancy. These were diagnosed accurately by the referring family practitioner in 22% of patients, while the dermatologists made the correct diagnosis prior to biopsy in 87%. CONCLUSIONS: In over 50% of cases diagnosed clinically, the dermatologist and family practitioner agreed. Histologically proven skin cancers were diagnosed accurately in only 22% of cases by family practitioners, compared to 87% of cases by dermatologists. Specific areas of diagnostic difficulty for family practitioners include benign pigmented actinic and seborrheic keratoses, squamous cell carcinoma, and melanoma. Postgraduate education for family practitioners should be directed towards these areas of deficiency. Dermatologists had difficulty distinguishing pigmented actinic keratoses from melanoma.     

The additive value of second opinion teleconsulting in the management of patients with challenging inflammatory,neoplastic skin diseases: a best practice model in dermatology?

BACKGROUND: Telemedicine is the practice of healthcare using interactive processes of communication to facilitate healthcare delivery, including diagnosis, consultation and treatment, as well as education and transfer of medical data. The aim of teledermatology, just as telemedicine, is to promote best practice procedures and to improve the consistency and competence of health care. AIM: To investigate the diagnostic additive value of second opinion teleconsulting in patients with challenging dermatoses, among dermatologists working in two different dermatology departments. SETTING: Thirty-three cases of patients with challenging inflammatory and neoplastic skin diseases at the University of L'Aquila Department of Dermatology were sent for teleconsultation to the Department of Dermatology, Medical University of Graz, Austria. METHODS: All cases were selected in the outpatient service in L'Aquila. After face-to-face consultation with a local colleague had been completed, images were sent using a store-and-forward (SAF)-based system (http://www.telederm.org) to Graz. Histopathological examination together with follow-up of the patient represents the diagnostic gold standard for this study. RESULTS: Telediagnosis was correct in 26 of 33 (78.8%) cases. Sixteen of 33 cases (48.5%) had already been diagnosed face-to-face by at least one of the two dermatologists in L'Aquila. In 10 of 33 cases (30.3%), the correct diagnosis was made in teleconsultation only. CONCLUSIONS: Second opinion teleconsulting may represent an additive value in the diagnosis of numerous challenging inflammatory and neoplastic skin diseases. It may be particularly useful as a best practice model for smaller departments in order to discuss and/or to confirm diagnoses and also for the management of patients with unusual difficult dermatoses.     

A comparison of real-time and store-and-forward teledermatology: a cost-benefit study

BACKGROUND: Increasing use of teledermatology should be based on demonstration of favourable accuracy and cost-benefit analysis for the different methods of use of this technique. Objectives To evaluate the clinical efficacy and cost-effectiveness of real-time and store-and-forward teledermatology. METHODS: Patients attended their own health centre and in the company of a general practitioner (GP) were seen by a hospital dermatologist over the videolink (real-time). Before the videolink consultation commenced, the GP took instant photographs of the skin lesion and posted them along with a standard referral letter to a different hospital dermatologist (store-and-forward). In total, 96 patients were seen by both real-time and store-and-forward teledermatology. Comparative diagnoses, clinical management plans, clinical outcomes and associated costs were made between the two types of teledermatology consultation. RESULTS: There was agreement between the videolink diagnosis and the still image diagnosis in 51% of cases. The same or similar management plan was recommended at both types of consultation in 44% of cases. Following the store-and-forward consultation the dermatologist recommended that 69% of patients required at least one hospital appointment compared with 45% of those patients seen in real-time. The net societal cost of the initial real-time consultation was pound132.10 per patient compared with £26.90 per patient for the initial store-and-forward consultation. CONCLUSIONS: The store-and-forward consultation was cheaper, but less clinically efficient, compared with the real-time consultation. The absence of interaction in a store-and-forward consultation limits the dermatologist's ability to obtain clinically useful information in order to diagnose and manage a patient satisfactorily.     

Comparison of skin biopsy triage decisions in 49 patients with pigmented lesions and skin neoplasms: store-and-forward teledermatology vs face-to-face dermatology

OBJECTIVE: To determine the relative efficacy of store-and-forward teledermatology vs face-to-face dermatology consultations in triage decisions about the need for a biopsy of neoplastic skin changes. DESIGN: Prospective study of consecutive patients judged by an internist to require dermatologic consultation for a skin growth. SETTING: Private primary care and dermatology practices and an academic dermatology practice. PATIENTS: Patients requiring dermatology consultation for evaluation of skin growths. Patients were seen by a single primary care physician between July 10, 1998, and August 4, 2000. INTERVENTION: Digital photographs of skin growths were obtained by the primary care physician and evaluated by a teledermatologist. The patient was then seen face-to-face by a dermatologist. A biopsy was performed if either dermatologist favored biopsy. MAIN OUTCOME MEASURES: Decisions to perform a biopsy. Agreement between the dermatologists was assessed. RESULTS: Of the 49 patients with evaluable photographs, the face-to-face dermatologist and teledermatologist recommended a biopsy for the same 26 patients, yielding a sensitivity of the teledermatologist of 1.00 (95% confidence interval [CI], 0.87-1.00) and a specificity of 1.00 (95% CI, 0.85-1.00). The agreement between the dermatologists (kappa) was 1.00 (95% CI, 0.72-1.00). CONCLUSION: Store-and-forward teledermatology may provide an accurate and cost-effective method of determining whether skin growths in patients presenting to primary care physicians should undergo biopsy.     

Patient satisfaction with teledermatology is related to perceived quality of life

BACKGROUND: There is a lack of good data about patient satisfaction with teledermatology and about its potential interaction with quality-of-life factors. OBJECTIVES: To assess the association between perceived skin-related quality of life and patient satisfaction with a nurse-led teledermatology service. METHODS: In a mobile nurse-led teledermatology clinic located in four inner city general practices in Manchester, the teledermatology service used digital cameras to capture and store images of skin conditions for remote diagnosis by dermatologists. One hundred and twenty-three adult patients, non-urgent dermatology referrals from primary care, completed the Dermatology Life Quality Index (DLQI) and a 15-item patient satisfaction questionnaire. RESULTS: In common with other studies of patient satisfaction, subjects reported highly favourable views of 'hotel' aspects of the service (93%) and found it 'convenient' (86%). However, 40% of patients would have preferred to have had a conventional face-to-face consultation with a dermatologist, and 17% felt unable to speak freely about their condition. Patient satisfaction with the service was related to quality of life. Patients reporting lower quality of life as measured by the DLQI were more likely to prefer a face-to-face encounter with a dermatologist (r = 0.216, P < 0.05), and to evince anxiety about being photographed (r = 0.223, P < 0.05). CONCLUSIONS: Patient acceptance and satisfaction with telemedicine services is complicated by patients' subjective health status. Telehealthcare providers need to recognize that patients with poor quality of life may want and benefit from face-to-face interaction with expert clinicians.     

Randomized controlled trial comparing store‐and‐forward teledermatology alone and in combination with web‐camera videoconferencing

Background. Studies on the reliability of teledermatology have shown considerable variability in results. Only one study has compared asynchronous and synchronous methods. Objectives. This report describes DERMATEL, a prospective, randomized diagnostic‐concordance study that sought to evaluate the relative advantages, in terms of reliability, of two remote consultation techniques. Methods. Patients referred by 18 general practitioners were randomized (4 : 4 : 2) to three study groups: store and forward (SF), hybrid videoconferencing‐SF (VC–SF), and a control group. In total, 457 patients were assigned: 192 to the SF group, 176 to the VC–SF group and 89 to the control group. High‐quality still images were used throughout, with additional use of standard web‐camera (webcam) videoconferencing in the VC–SF group. All patients were also seen by the same dermatologist in a face‐to‐face (FTF) consultation, considered the practical reference standard. Two different dermatologists assessed concordances between the teledermatology and FTF consultations. Results. There were no significant differences in age, gender or diagnostic category between the three groups, and the images (82%), clinical history (91%) and diagnostic confidence (89%) were high‐quality. Online management was possible for 70% of cases. Agreement between teledermatology and the FTF consultation was high for both diagnosis (> 0.85) and treatment (> 0.78). Concordance in diagnosis was influenced by image quality (P < 0.001), confidence in diagnosis (P < 0.001) and need for conventional consultation (P < 0.001), rather than by quality of clinical history (P = 0.58) or method of teleconsultation (P = 0.340). Conclusions. Intraobserver reliability is very high in teledermatology. When history taking and training in digital photography are standardised, a hybrid system with audio is no better than SF alone.     

Teledermatología en Chile: experiencia de su implementación temprana

IntroductionAsynchronous Teledermatology (ATD) is a valuable tool that provides remote dermatological care and helps improve access and timeliness of specialized medical care. Through ATD, dermatologists can remotely review patients' images and medical history, making diagnostic and therapeutic suggestions.ObjectiveTo assess the level of agreement between the diagnosis given by the general practitioner in primary care and the diagnosis given by a dermatologist using the ATD platform, globally and by diagnostic group. To evaluate how many of the patients that through the platform could continue their treatment and controls in primary care.Materials and methods12,459 teleconsultations uploaded to the Ministry of Health's (MINSAL) electronic platform of ATD from January 2011 to September 2017, from the health services of Valparaiso-San Antonio, Metropolitano Oriente, Metropolitano Occidente and Valdivia.ResultsThe level of global diagnostic agreement was 65.3%. However, when analyzing the agreement of the diagnoses that presented a prevalence greater than 1% of the sample, this concordance rises to 72.4%. Finally, 64% of the teleconsultations continued the treatment in the context of primary care, while 30.1% were referred to face to face dermatological care.DiscussionThis study shows a moderate to high level of agreement between the doctor in the primary care and the dermatologist remotely. In this context, ATD helps to ratify the diagnosis of the general practitioner in 65 to 72% of the cases, but also helps to correct diagnoses in 38 to 45% of cases. In addition, it allows for more than 60% of the patients to continue their treatment and follow up in the primary care, thus, avoiding unnecessary referral to the secondary care.     

Newer insights in teledermatology practice

The study and practice of dermatology care using interactive audio, visual, and data communications from a distance is called teledermatology. A teledermatology practice (TP) provides teleconsultation as well tele-education. Initially, dermatologists used videoconference. Convenience, cost-effectiveness and easy application of the practice made "store and forward" to emerge as a basic teledermatology tool. The advent of newer technologies like third generation (3G) and fourth generation (4G) mobile teledermatology (MT) and dermatologists' interest to adopt tertiary TP to pool expert (second) opinion to address difficult-to-manage cases (DMCs) has resulted in a rapid change in TP. Online discussion groups (ODGs), author-based second opinion teledermatology (AST), or a combination of both are the types of tertiary TP. This article analyzes the feasibility studies and provides latest insight into TP with a revised classification to plan and allocate budget and apply appropriate technology. Using the acronym CAP-HAT, which represents five important factors like case, approach, purpose, health care professionals, and technology, one can frame a TP. Store-and-forward teledermatology (SAFT) is used to address routine cases (spotters). Chronic cases need frequent follow-up care. Leg ulcer and localized vitiligo need MT while psoriasis and leprosy require SAFT. Pigmented skin lesions require MT for triage and combination of teledermoscopy, telepathology, and teledermatology for diagnosis. A self-practising dermatologist and national health care system dermatologist use SAFT for routine cases and a combination of ASTwith an ODG to address a DMC. A TP alone or in combination with face-to-face consultation delivers quality care.     

Teledermatology: an intraobserver diagnostic correlation study,part I

Many studies have been published recently on the effectiveness of teledermatology as a diagnostic tool; however, much of the data comes from live 2-way video teleconferencing consultations and very little comes from more readily available "store and forward" consultations. Moreover, most published studies compare the diagnoses of 2 different dermatologists (interobserver comparison). Given the lack of data on baseline interdermatologist diagnostic variability, the interpretation of currently available diagnostic correlation data is somewhat difficult. The objective of this study is to measure the degree of diagnostic concordance between a dermatologist seeing a patient via a teledermatology consult system and the same dermatologist seeing the same patient face-to-face in a dermatology clinic at a tertiary medical center. A random sample of 404 patients was selected from patients who had routine appointments at our dermatology clinic.     

Teledermatoscopy as a triage system for pigmented lesions: a pilot study

BACKGROUND: Skin-cancer screening should rely on simple, low-cost and high-sensitivity diagnostic procedures. AIMS: To compare diagnosis and management options after the evaluation of clinical and dermatoscopic teleconsultations with a store-and-forward teledermatology screening system for pigmented lesions. METHODS: Kappa values between telediagnoses and the gold standard (histological examination) were assessed. Referral rates, diagnostic confidence level (DCL), sensitivity and specificity were evaluated in both approaches. Picture quality and time and cost investments were also measured. In total, 61 teleconsultations were evaluated. RESULTS: Sensitivity of the clinical and dermatoscopic teleconsultations was 1 for both, whereas specificities were 0.65 and 0.78, respectively (P < 0.05). DCL was higher for the dermatoscopic teleconsultations (4.75 vs. 4.14, P < 0.05). Agreement between the clinical and dermatoscopic teleconsultation was kappa = 0.89 (95% CI 0.81-0.97). Agreement with the gold standard was 0.91 (95% CI 0.82-1.00) for the clinical teleconsultation and 0.94 (95% CI 0.88-1.00) for teledermatoscopy (P > 0.05). Teledermatoscopy increased the economic investment of a teledermatology facility by 2.4 times. The GP spent 1.5 times longer on dermatoscopic teleconsultations. CONCLUSIONS: Teledermatoscopy has improved the DCL, specificity and referral rates of a teledermatology-based screening system for pigmented lesions. A more detailed economic analysis remains to be performed before recommending teledermatoscopy as a routine screening procedure in pigmented-lesion clinics.     

Successful triage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT trial)

Background Teledermatology is a rapidly growing field with studies showing high diagnostic accuracy when compared with face‐to‐face diagnosis. Teledermoscopy involves the use of epiluminescence microscopy to increase diagnostic accuracy. The utility of teledermoscopy as a triage tool has not been established. Objectives To assess teledermoscopy as a triage tool for a hospital skin lesion clinic. Methods Patients referred to a dermatology skin lesion clinic were recruited. Digital and dermoscopic photographs were taken of skin lesions of concern and the patients were then seen independently face‐to‐face by two out of three dermatologists. The digital images were evaluated 4 weeks later, as a teledermoscopy consultation, by two of these dermatologists. The diagnosis and management from both types of consultation were compared. Results Two hundred patients with a total of 491 lesions were seen. There was excellent agreement between teledermoscopy and face‐to‐face diagnosis with only 12·3% of lesions having disparate diagnoses of clinical significance. Twelve of 491 (2·4%) lesions appeared to have been under‐reported by teledermoscopy when compared with face‐to‐face diagnosis. However, when histopathology became available, only one malignant lesion had been missed (a basal cell carcinoma diagnosed as solar keratosis) by teledermoscopy. Teledermoscopy approximated 100% sensitivity and 90% specificity for detecting melanoma and nonmelanoma skin cancers. Importantly, 74% of all lesions were determined to be manageable by the general practitioner without needing to be seen face‐to‐face by a dermatologist. Conclusions This use of teledermoscopy as a triage tool offers the potential to shorten waiting lists and thus improve healthcare access and delivery.     

Using cellphones for teledermatology, a preliminary study

We compared live and instantaneous digital image examination of hospitalized dermatology consultation patients and to assess the reliability and the practicality of a teledermatology system equipped with the cellular phone cameras. A dermatology resident examined ten hospitalized dermatology consultation patients. Then a medical student took digital pictures of these lesions from consenting patients with a cell phone camera. The pictures were forwarded to a supervising dermatologist who was able to review them using the identical phone. The differential diagnoses given by the resident and the supervising dermatologist were recorded. Identifiable facial images were never taken. The concordance of the diagnoses between resident and off site attending was 80 percent (8/10 cases) when a diagnosis could be made remotely. In one case no diagnosis could be made because of poor photographic quality and small screen and in one case the attending diagnosis was incorrect. The practicality of this cellular phone camera teledermatology system depended on the Sprint wireless network, which was sometimes unreliable. Cellular phones with cameras offer a means to deliver bedside supervision of dermatology residents but transmission issues, small screen size, and photographic quality complicate their use.     

Fiabilidad de la teledermatología de almacenamiento en un escenario real

Introduction and objectivesAlthough many studies have evaluated the diagnostic reliability of store-and-forward (SF) teledermatology, the reliability of the technique for the diagnosis of general skin conditions in a clinical practice setting has never been demonstrated. We evaluated the reliability of SF teledermatology in clinical practice by analyzing the diagnostic agreement achieved in a subgroup of patients from the DERMATEL-2 study.Material and methodsPatients referred from primary care settings were randomized to 3 groups: SF, a combination of videoconferencing and SF technology (VC-SF), and a control group. This article focuses on the SF group. Clinical data were recorded and photographs taken by primary care physicians, who forwarded the data electronically. Each SF consultation package was assessed by 3 dermatologists (D1,D2,D3). Subsequently all the patients were assessed by a single dermatologist (D1) in a face-to-face consultation. Finally, 2 other dermatologists (D4,D5) assessed the agreement between the diagnoses obtained by SF and FF.ResultsIn total, 457 patients (200 males and 257 females) aged between 2 months and 86 years were randomized (192 to SF, 176 to VC-SF, and 89 to the control group). The diagnostic categories were as follows: tumors (49.4%), inflammatory (25.7%), adnexal (11%), infectious (9.4%) and other processes (4.4%) Since 170 patients had consultations deemed valid for analysis, the study included a total of 510 SF assessments. Most of the images and clinical records were of high quality (71.2% and 91.2% respectively), and diagnostic confidence was high in 81.4% of the cases studied.In 58.4% of cases the condition was managed exclusively by teledermatology. Levels of complete and aggregate interobserver agreement between SF and face-to-face evaluators were 0,72 and 0.90, respectively, for diagnosis and 0.61 and 0.80 for treatment. Diagnostic agreement correlated with the image quality (P  <  .001), diagnostic confidence (P < .001), felt need for conventional consultation (P < .001), and the quality of the clinical record (P = .013).ConclusionThe interobserver reliability of SF diagnosis in clinical practice is good. Dermatologists are able to predict errors in diagnosis by analyzing their own diagnostic confidence and evaluating the quality of the images.