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.     

Authors’ willingness for second‐opinion teledermatology in difficult‐to‐manage cases: ‘an online survey’

Background Expert non‐availability for an instant difficult‐to‐manage case may limit the online discussion group to provide second‐opinion teledermatology for registered dermatologists. Author‐based second‐opinion teledermatology (AST) is proposed and assessment of authors’ response to answer queries and their willingness to participate in teledermatology consultation is analysed. Materials and methods Authors of 292 articles from seven non‐open access dermatology and three general medical journals addressing difficult‐to‐manage cases from June 2007 to December 2008 participated in this online dermatology authors’ survey. Authors’ response to reprint requests, answer literature queries and willingness to offer second‐opinion teledermatology were the main outcome measures. Perceived views were also documented. Results The scores for reprints requests vs. received were (χ² = 13.57, n = 292), P = 0.000. The scores for articles read, analysed and literature queries sent vs. authors answered were (χ² = 11.09, n = 190), P = 0.001. The scores for authors responded to reprints vs. willing to offer second‐opinion teledermatology consultation were (χ² = 5.65, n = 190), P = 0.017 and authors responded to reprint requests, answered queries and willing to offer second‐opinion (χ² = 5.65, n = 190), P = 0.017. Conclusion A dermatologist obtains literature, answered queries and constructive suggestions with additional informative material and pools second‐opinions from the authors using their e‐mail to deliver quality health care. AST is an alternative to online discussion group for second‐opinion teledermatology practice in difficult‐to‐manage cases. Uniform international laws are to be framed to facilitate telemedicine care for a difficult‐to‐manage case.     

Photoepilation with a diode laser vs. intense pulsed light: a randomized,intrapatient left‐to‐right trial

Background Safe and efficient options for removing unwanted hair are in great demand. Laser devices and intense pulsed light (IPL) sources are the most commonly used treatment modalities. Yet, only a few randomized controlled trials (RCTs) comparing laser and IPL devices are available, and RCTs with long‐term results are missing from the literature. Objectives To compare the safety and long‐term efficacy of diode lasers (DL) and IPL sources for axillary hair removal, we conducted an intrapatient, left‐to‐right, assessor‐blinded and controlled trial. Methods IPL (Ellipse Flex PPT; Danish Dermatological Development, Hoersholm, Denmark; λ_em = 600–950 nm) and DL (LightSheer XC system; Lumenis Inc., Santa Clara, CA, U.S.A.; λ_em = 800 nm) treatments were evaluated in 30 study participants (skin type II–III) with unwanted axillary hair growth. Six treatments with each device were carried out at 4‐week intervals. Final assessment was conducted 12 months after the last treatment by means of hair counts using close‐up photographs. The primary endpoint was reduction in hair growth, analysed on an intention‐to‐treat and last‐observation‐carried‐forward basis (n = 30), and secondary endpoints were patient‐rated efficacy, treatment‐related pain, adverse effects and treatment duration. Results Both devices significantly reduced hair counts. Mean reductions from baseline (3 and 12 months after the last treatment) were 59·7% and 69·2% for DL and 42·4% and 52·7% for IPL treatment (P < 0·01), respectively. DL treatment induced significantly more pain [3·7 ± 2·1 (DL) vs. 1·6 ± 1·4 (IPL); P < 0·01; visual analogue scale] but could be conducted faster [33·1 ± 3·8 s (DL) vs. 40·1 ± 5·0 s (IPL); P < 0·01]. No severe side‐effects were observed for either therapy. Conclusions Both DL and IPL treatments are highly effective, long lasting and safe. DL was found to be more effective than IPL treatment. DL treatment was more painful but less time‐consuming than IPL therapy.     

Intense pulsed light vs. pulsed‐dye laser in the treatment of facial acne: a randomized split‐face trial

Background Various laser and light therapy have been increasingly used for the treatment of acne vulgaris. Patients and methods Twenty patients with facial acne were treated using intense pulsed light (IPL) on one side of the face and pulsed dye laser (PDL) on the other to compare the efficacy and safety of IPL and PDL. Treatment was performed 4 times at 2‐week intervals. Treatment effectiveness was determined using lesion counts, acne severity, patient subjective self‐assessments of improvement, and histopathological examinations, which included immunohistochemical staining for transforming growth factor‐β (TGF‐β). Results Numbers of total acne lesions decreased following both treatments. For inflammatory lesions such as papules, pustules and nodules, IPL‐treated sides showed an earlier and more profound improvement than PDL‐treated sides. However, at 8 weeks after the 4th treatment, a rebound aggravation of acne was observed on IPL‐treated sides. On the contrary, PDL produced gradual improvements during the treatment sessions and these improvements lasted 8 weeks after the 4th treatment. Non‐inflammatory lesions as open and closed comedones also showed improvement following both treatments and PDL‐treated sides showed better improvement as the study proceeded. Histopathological examinations showed amelioration in inflammatory reactions and an increase in TGF‐β expression after both treatments, which were more prominent for PDL‐treated sides. Conclusion Both PDL and IPL were found to treat acne effectively, but PDL showed a more sustained effect. TGF‐β might play a key role in the resolution of inflammatory acne lesions.     

Methotrexate vs. fumaric acid esters in moderate‐to‐severe chronic plaque psoriasis: data registry report on the efficacy under daily life conditions

Objective To compare the clinical efficacy of methotrexate (MTX) vs. fumaric acid esters (FAE) in psoriasis treated under daily life conditions. Methods Data were extracted from a registry ( http://www.psoriasisregistry.at ) of 272 adult patients with moderate‐to‐severe chronic plaque psoriasis treated primarily with MTX (n = 72) or FAE (n = 200) between 2004 and 2011. Data from all patients, including those who did not complete at least 3 months of monotherapy, were included in an intention‐to‐treat (ITT) worst‐case analysis. Results Thirty of 72 (41.7%) patients treated with MTX and 85 of 200 (42.5%) patients treated with FAE discontinued early, mainly due to side‐effects or lack of response. Among patients who completed at least 3 months of treatment, the response to primary treatment with MTX vs. FAE did not differ significantly at any time point. In the ITT worst‐case analysis at month 3, complete remission rate, PASI90, PASI75 and PASI50 rates were 6%, 7%, 24% and 39% in MTX‐treated patients vs. 1%, 5%, 27% and 44% in FAE‐treated patients. Overall mean PASI reduction score improved significantly in response to primary MTX and FAE treatment (by 10.6% and 12.6%, respectively) between 3 and 6 months (P = 0.0005; exact Wilcoxon test), but not between 6 and 12 months (P = 0.16). A subset of 32 patients who did not respond satisfactorily to primary treatment with FAE responded better to subsequent MTX therapy (P < 0.0001; paired Wilcoxon test). Conclusions As shown by retrospective analysis, the primary efficacy of FAE was similar to that of MTX under daily life conditions.     

Virtual Grand Rounds in Dermatology: an 8‐year experience in web‐based teledermatology

Background Teledermatology utilizes telecommunication technologies for the exchange of dermatologic information across distances. In 2000, we developed the Virtual Grand Rounds in Dermatology (VGRD) as a free, user‐friendly platform for dermatologists to present complex dermatologic cases to the international community for clinical feedback, consultation, and continuing education. Methods VGRD was designed using simple graphics to facilitate access in remote and developing geographic regions. Members present their case according to a recommended template and are encouraged to provide clinical and histopathologic photographs. Viewers’ comments are posted on the site within 24–48 h following receipt. Results VGRD's low‐cost store‐and‐forward system allows easy accessibility to expertise for colleagues around the world. VGRD currently comprises a community of 344 clinicians across all dermatologic subspecialties, and links users to cases as well as a recent interactive addition for more urgent feedback: VGRD Blog. The Maine Virtual Skin Clinic is another sister site developed as an educational tool for physicians and residents in primary care. VGRD can be found at http://www.vgrd.org . Conclusions With its easy‐to‐use platform for teleconsultation services, VGRD has the potential to enhance clinical outcomes and education. In the next few years, we hope to continue to expand VGRD, including launching a comprehensive search engine in VGRD to provide users with a “one‐stop resource.” With the growth of teledermatology, we will combine web consultations with web‐based education into a single resource for dermatologists interested in new possibilities in clinical practice, patient care, and continuing education.     

Single vs. fractionated photodynamic therapy for face and scalp actinic keratoses: a randomized,intraindividual comparison trial with 12‐month follow‐up

Objective To compare the efficacy and tolerability of a single ALA‐PDT illumination scheme with that of a fractionated ALA‐PDT illumination scheme in face and scalp actinic keratoses (AKs). Methods Eligible patients received either a single ALA‐PDT illumination or a fractionated illumination scheme randomly allocated to alternate sides of face/scalp. The side allocated to a single illumination received 75 J/cm². This side received 2 sessions performed 7 days apart. Lesions on the fractionated illumination scheme side received 20 and 80 J/cm², 4 and 6 hours after a single ALA application. Patients were evaluated at baseline, at 3 and 12 months after treatment. Efficacy end point included the individual AK lesion clearance rate. Results Thirty three patients with 266 lesions were enrolled in the study. Three months after treatment the overall lesion complete response rate was 89.05% for the single scheme and 96.12% for the fractionation scheme while at the 12‐months follow‐up response rate decreased to 85.4% for the single illumination and to 93.79% for the fractionated illumination group. Looking at lesion response based on lesion grade fractionated photodynamic therapy (PDT) resulted in larger rates of cured grade I as well as grade II lesions. Recorded adverse events were transient and did not demand additional therapy. Conclusions Our results demonstrate that higher responses are achieved with fractionated PDT compared with single illumination PDT. The study data indicate that fewer treatment sessions may be needed with fractionated PDT increasing that way the comfort of the patient regarding number of visits, treatment cost and treatment‐related downtime.