Melanoma Detected Through Teledermatology Versus In-Person Visits

Background: Early detection of melanoma improves survival; however, patients face long wait times to receive dermatology care. Teledermatology (TD) is a promising tool to optimize access to care and has shown promise for the identification of malignancies but has not been well studied for melanoma. We evaluated the utility of TD as a triage tool to allow high-risk lesions of concern to be seen more expeditiously. Methods: Patient sociodemographic factors and histological characteristics of 836 melanomas biopsied between March 2020 and November 2022 in the University of Pittsburgh Medical Center health system were retrospectively evaluated, stratified by initial appointment type of TD versus in-person visit. Results: Patients first seeking care through teledermatology had shorter wait times to initial evaluation (p < 0.001) and eventual biopsy (p < 0.001), and these melanomas had higher Breslow thickness (p < 0.001), were more ulcerated (p = 0.002), invasive (p = 0.001), and of a more aggressive subtype (p = 0.007) than those initially evaluated in-person. TD was also utilized by a higher proportion of younger (p = 0.001) and non-white (p = 0.03) patients who identified their own lesion (p < 0.001). Conclusions: TD may be a strategy to improve melanoma outcomes by providing an accessible avenue of expedited care for high-risk lesions associated with worse clinical prognosticators of disease.

Descriptive and Concordance Data for Asynchronous Teledermatology Consultations for Dermatitis: A Retrospective Study

Background: Implementation of teledermatology for assessing dermatitis patients provides comparable diagnostic and management outcomes to in-person visits, but studies on consumer to physician asynchronous teledermatology (eDerm) consults submitted by patients in large dermatitis cohorts are limited. The objective of this study was to retrospectively assess associations of eDerm consults with diagnostic accuracy, management, and follow-up in a large cohort of dermatitis patients. Methods: One thousand forty-five eDerm encounters between April 1, 2020, and October 29, 2021, recorded in the University of Pittsburgh Medical Center Health System Epic electronic medical record were reviewed. Descriptive statistics and concordance were analyzed using chi-square. Results: Asynchronous teledermatology modified/changed treatment in 97.6% of cases and had the same diagnosis between teledermatology and in-person follow-up in 78.3% of cases. Patients following up in the time line requested were more likely to follow-up in person (61.2% vs. 43.8%) than those who did not. Patients with intertriginous dermatitis (p = 0.003), preexisting conditions (p = 0.002), who required follow-ups (<0.0001), and moderate-high severity scores of 4-7 (p = 0.019) were more likely to follow up in the time line requested. Limitations: Lack of similar in-person visit data did not allow us to compare descriptive and concordance data between eDerm and clinic visits. Conclusions: eDerm offers a quick accessible solution to provide comparable dermatologic care for patients with dermatitis.

Hydroxychloroquine-induced repetitive atypical pustular drug eruptions in the same patient separated by 12 years

Hydroxychloroquine (HCQ) has been reported to cause pustular drug eruptions such as acute generalized exanthematous pustulosis (AGEP) and putular psoriasis (PP). Clinical differentitation of these entities is often difficult. This case emphasizes characteritics of AGEP and PP as well as the need for clinicans to proactively follow-up these patients to monitor for the more aggressive outcome of PP.

Inpatient Teledermatology: a Review

Purpose of Review

Inpatient teledermatology is a rapidly growing field with significant potential to add value and streamline patient care. This review summarizes the current literature on inpatient teledermatology, primarily focusing on its diagnostic and clinical management utility as compared to live dermatologic evaluation.

Recent Findings

The COVID-19 pandemic has accelerated the adoption of inpatient teledermatology, which has been shown to be comparable to live hospitalist evaluation for triage, diagnosis, and management of hospitalized patients for a wide variety of conditions. Despite its comparative cost-effectiveness and recent changes in reimbursement practices, inpatient teledermatology still lacks sufficient reimbursement incentive for widespread implementation.

Summary

Inpatient teledermatology is an effective, efficient, accurate, and cost-effective means of managing the hospital burden of skin disease, especially in areas where access to dermatologic care is limited. It is essential that dermatologists and referring providers comprehend the use and potential pitfalls of inpatient teledermatology to effectively incorporate it into hospital practice.

Refractory Cutaneous Dermatomyositis With Severe Scalp Pruritus Responsive to Apremilast

ABSTRACT

Dermatomyositis (DM) is a subset of idiopathic inflammatory myopathy with characteristic cutaneous manifestations and muscle weakness. Conventional treatments for DM include glucocorticoids and other immunosuppressive or immunomodulatory agents including hydroxychloroquine, methotrexate, azathioprine, mycophenolate mofetil, tacrolimus, cyclosporine, and intravenous immunoglobulin. Refractory patients require more aggressive or novel therapies. Apremilast has not been studied for the management of refractory cutaneous DM. We report a case of a patient with refractory DM with severe scalp pruritus treated with apremilast who demonstrated significant improvement in her skin disease and complete resolution of scalp pruritus.

Inpatient Teledermatology Improves Diagnostic Accuracy and Management of Erythroderma in Hospitalized Patients

Inpatient asynchronous or store-and-forward teledermatology has been studied to a limited degree despite unprecedented use of teledermatology during the coronavirus pandemic and a high demand for inpatient dermatology services.¹ Involvement of dermatology hospitalists in inpatient settings has shown to improve outcomes and reduce time to response; however, few studies have evaluated the impact of teledermatology on inpatient dermatologic management including its ability to increase efficiency and better outcomes.

Access to consultative dermatologic care via physician-to-physician asynchronous outpatient teledermatology

OBJECTIVES

To determine whether physician-to-physician outpatient asynchronous store-and-forward teledermatology can be a portal for patient access to consultative dermatologic care and decrease primary care physician referrals to dermatology.

STUDY DESIGN

Retrospective study.

METHODS

Reviewed outpatient teledermatology consults completed within a shared Epic electronic health record at the University of Pittsburgh Medical Center (UPMC) Health System between August 4, 2013, and December 19, 2019. Study data were reviewed for consult response time and triage percentage. Patient and physician experiences were collected by satisfaction surveys.

RESULTS

This study reviewed 1581 teledermatology consults that originated from UPMC primary care provider (PCP) appointments. The average response time for a completed consult was 1 hour, 13 minutes for same-day consult submissions. The majority of consults, 63%, were completed online, whereas only 37% of patients were recommended for an in-person referral visit to the dermatology clinic. Surveyed patients (81%) and PCPs (90%) responded positively to their teledermatology experience.

CONCLUSIONS

Physician-to-physician outpatient asynchronous teledermatology consults can provide a model for rapid consultation and decreased primary care referral to dermatology.

A Framework-Driven Systematic Review of the Barriers and Facilitators to Teledermatology Implementation

Purpose of Review

Telemedicine use in dermatology, termed “teledermatology”, offers a cost-effective model to improve healthcare efficiency and access. Only a minority of dermatology practices has integrated teledermatology into their practice prior to COVID-19. A thorough understanding of the barriers and facilitators may promote teledermatology adoption. Implementation science frameworks offer theoretically driven ways to assess factors affecting teledermatology implementation. This review uses a comprehensive implementation science framework to summarize barriers and facilitators of teledermatology implementation and appraises the quality of existing research.

Recent Findings

Technological characteristics of teledermatology (e.g., user-friendliness) and factors within the outer setting (e.g., reimbursement and legal considerations) were the most commonly reported barriers. No existing studies use a comprehensive implementation framework to identify factors influencing teledermatology implementation. Many included studies have a risk of bias in at least two of the five study quality indices evaluated.

Summary

This systematic review is the first study to summarize the existing teledermatology implementation literature into well-defined constructs from a comprehensive implementation science framework. Findings suggest future studies would benefit from the use of an implementation framework to reduce study bias, improve result comprehensiveness, facilitate comparisons across studies, and produce evidence-based resolutions to implementation barriers. Tools, resources, and recommendations to facilitate the use of an implementation framework in future studies are provided.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13671-020-00323-0.

Utilization of Asynchronous and Synchronous Teledermatology in a Large Health Care System During the COVID-19 Pandemic

Background: Teledermatology offers an opportunity to continually deliver care during the coronavirus disease 2019 pandemic. Objective: To provide quantitative data about the use of teledermatology. Methods: Retrospective analysis of teledermatology consultations was performed from March 16 to May 1, 2020. The number/type of encounters, differences in diagnoses, and prescriptions between asynchronous and synchronous teledermatology visits were analyzed. Results: A total of 951 visits (36.2%) were asynchronous whereas 1,672 visits (63.8%) were synchronous. Only 131 (<5%) visits required an acute in-person follow-up. The diagnosis of acne was more frequent with asynchronous visits (p < 0.002, Bonferroni corrected). Antibiotics and nonretinoid acne medications were prescribed more with asynchronous visits, whereas immunomodulators and biologics were more commonly prescribed with synchronous visits (p < 0.02, Bonferroni corrected). Providers at our institution were split on preferred mode (54.2% synchronous, 45.8% asynchronous); however, synchronous visits were preferred for complex medical dermatology patients and return patients (p < 0.05). Limitations: This study is limited by being a single-center study. Conclusions: Asynchronous teledermatology was used more for acne management, whereas synchronous teledermatology was preferable to providers for complex medical dermatology. Postanalysis of the data collected led us to institute a hybridization of our asynchronous and synchronous teledermatology.

Inpatient eDermatology (Teledermatology) Can Help Meet the Demand for Inpatient Skin Disease

Background: Currently, the number of inpatient dermatology providers cannot meet the overall burden of inpatient skin disease in the United States. Introduction: We seek to determine whether inpatient eDermatology can meet the need for inpatient skin disease in hospitals without access to a dermatology hospitalist. Methods: This retrospective cohort study reviewed inpatient eDermatology consults at the University of Pittsburgh eDermatology Consult Service between July 1, 2014 and June 30, 2018. This included a diverse group of 1,320 patients admitted to 10 different community hospitals. Study data were reviewed for demographics, diagnostic impressions, time to discharge, and diagnostic discordance between referring and consultant physicians. Results: Forty percent of inpatient eDermatology consults were admitted with a primary dermatologic diagnosis. Referring diagnosis most commonly was rash not otherwise specified. eDermatology consulting impressions, conversely, were specific and varied. Ninety-one percent of patients received a consultant impression by the end of day, or within 8 hours. Overall, 89.3% of patients with a referring diagnosis of "cellulitis" were given a different diagnosis by the consultant. Discussion: Although this study lacked concordance data to compare the Inpatient eDermatologist with a live Inpatient Dermatologist, overall, eDermatology consultants were able to provide rapid consult recommendations that aided patient management. Conclusions: Inpatient eDermatology appears to be an effective medium to provide dermatologic care to patients at hospitals without a dermatology presence. This delivery of health care can help prevent misdiagnosis, unnecessary costs, and inappropriate systemic therapies.

Grover’s Disease Treated With Total Skin Electron Beam Radiotherapy

Persistent Grover's disease can cause significant symptoms of pruritus thereby decreasing quality of life. Many patients undergo successful conservative management of their disease; however, a subset of patients is recalcitrant despite multiple lines of therapy. Accordingly, we present, to our knowledge, the first reported case of recalcitrant Grover's disease treated successfully with radiotherapy. J Drugs Dermatol. 2019;18(4):392-393.

Nonscarring alopecia associated with vitamin D deficiency

Vitamin D is well known for its role in bone health and immune regulation, playing a role in cell differentiation, proliferation, and apoptosis. Vitamin D deficiency also has been associated with various forms of nonscarring hair loss. We describe a notable case of nonscarring alopecia associated with only vitamin D deficiency in which vitamin D replacement therapy helped promote hair regrowth. We also discuss diagnosis, prevention, and treatment of vitamin D deficiency.

Teledermatology: A Review and Update

Telemedicine is slowly transforming the way in which healthcare is delivered and has the potential to improve access to subspecialty expertise, reduce healthcare costs, and improve the overall quality of care. While many subspecialty fields within medicine today have either experimented with or begun to implement telemedicine platforms to enable remote consultation and care, dermatology is particularly suited for this care system as skin disorders are uniquely visible to the human eye. Through teledermatology, diagnostic images of skin disorders with accompanying clinical histories can be remotely reviewed by teledermatologists by any number of modalities, such as photographic clinical images or live video teleconferencing. Diagnoses and treatment recommendations can then be rendered and implemented remotely. The evidence to date supports both its diagnostic and treatment accuracy and its cost effectiveness. Administrative, regulatory, privacy, and reimbursement policies surrounding this dynamic field continue to evolve. In this review, we examine the history, evidence, and administrative landscape surrounding teledermatology and discuss current practice guidelines and ongoing controversies.

Inter-rater reliability of cutaneous sarcoidosis assessment tools via remote photographic assessment

Background: Recently two outcome instruments have been developed and validated for assessing cutaneous sarcoidosis in a live, in-person setting. Teledermatology is a rapidly growing field; yet, to date, no instrument has been validated for use in a remote setting, which could ultimately impact clinical trial design. Objective: To assess the interrater reliability of these outcome instruments for store-and-forward teledermatology. Methods: Seven sarcoidosis experts, including both pulmonologists and dermatologists, scored photographs of cutaneous sarcoidosis lesions in 13 patients utilizing the Cutaneous Sarcoidosis Activity and Morphology Index (CSAMI), the Sarcoidosis Activity and Severity Index (SASI) and the Physician Global Assessment (PGA). Interrater reliability was assessed for each instrument and was compared to results obtained from a prior study involving sarcoidosis experts evaluating the same patient population in an in-person setting. Results: Interrater reliability (presented as ICC [95%CI]) was poor for the CSAMI Activity scale (0.36 [0.16 - 0.65]) and the CSAMI Damage scale (0.17 [0.04 - 0.43]) and was fair for the Modified Facial SASI (0.59 [0.36 - 0.82]) and the PGA (0.47 [0.23 - 0.74]). All results were inferior to those obtained from the prior studies validating these instruments for in-person use. Conclusions: Given the superiority of these instruments when utilized in person, it is recommended to have an on-site sarcoidosis expert evaluate cutaneous sarcoidosis lesions whenever possible. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 165-169).

Sofosbuvir-Induced Erythrodermic Pityriasis Rubra Pilaris-Like Drug Eruption

Until 2011, the standard-of-care therapy for patients with hepatitis C consisted of interferon and ribavirin. The recent advent of new targeted therapies against this virus has provided more options of treatment for infected patients. Sofosbuvir, a nucleotide inhibitor of hepatitis C virus (HCV) RNA polymerase, was recently approved by the US Food and Drug Administration in 2013. Various Phase 3 trials with sofosbuvir combination therapy have reported an incidence of rash between 7% and 18%. We here describe a case of sofosbuvir-induced erythrodermic pityriasis rubra pilaris-like drug eruption.

Indoor Tanning, Skin Cancer and the Young Female Patient: A Review of the Literature

Young, non-Hispanic white females represent the population most likely to use indoor tanning facilities. This population may be at increased risk of skin cancer as recent meta-analyses support a strong association between cutaneous malignancy and indoor tanning. Public perception of the purported health benefits of indoor tanning may be partially to blame for the popularity of tanning salons as a desire to prepare skin prior to sun exposure is among the most commonly cited motivations for indoor tanning. Improving education and counseling to address misconceptions regarding tanning safety will require the participation of healthcare providers for both physical and psychological screenings as well as for information dissemination. This review presents the association between tanning bed use and skin cancer, biological effects of UV radiation exposure, UV burden associated with tanning devices, public perception of tanning, demographic and psychological profile of indoor tanners, and current legislation regulating tanning bed use.

Reactive Granulomatous Dermatitis: A Review of Palisaded Neutrophilic and Granulomatous Dermatitis, Interstitial Granulomatous Dermatitis, Interstitial Granulomatous Drug Reaction, and a Proposed Reclassification

The terms "palisaded neutrophilic and granulomatous dermatitis," "interstitial granulomatous dermatitis," and the subset "interstitial granulomatous drug reaction" are a source of confusion. There exists substantial overlap among the entities with few strict distinguishing features. We review the literature and highlight areas of distinction and overlap, and propose a streamlined diagnostic workup for patients presenting with this cutaneous reaction pattern. Because the systemic disease associations and requisite workup are similar, and the etiopathogenesis is poorly understood but likely similar among these entities, we propose the simplified unifying term "reactive granulomatous dermatitis" to encompass these entities.

Phytophotodermatitis

Phytophotodermatitis is a phototoxic cutaneous eruption due to skin exposure to furocourmarins combined with ultraviolet light. Bizzare linear patterns, ranging from erythema to bullae with residual hyperpigmentaion, is the clinical clue to this diagnosis. Avoidance of furocoumarins in direct sunlight can prevent recurrences.

EYA4 is inactivated biallelically at a high frequency in sporadic lung cancer and is associated with familial lung cancer risk

In an effort to identify novel biallelically inactivated tumor suppressor genes (TSG) in sporadic invasive and pre-invasive non-small cell lung cancer (NSCLC) genomes, we applied a comprehensive integrated multi-‘omics approach to investigate patient matched, paired NSCLC tumor and non-malignant parenchymal tissues. By surveying lung tumor genomes for genes concomitantly inactivated within individual tumors by multiple mechanisms, and by the frequency of disruption in tumors across multiple cohorts, we have identified a putative lung cancer TSG, Eyes Absent 4 (EYA4). EYA4 is frequently and concomitantly deleted, hypermethylated and underexpressed in multiple independent lung tumor data sets, in both major NSCLC subtypes, and in the earliest stages of lung cancer. We find not only that decreased EYA4 expression is associated with poor survival in sporadic lung cancers, but EYA4 SNPs are associated with increased familial cancer risk, consistent with EYA4’s proximity to the previously reported lung cancer susceptibility locus on 6q. Functionally, we find that EYA4 displays TSG-like properties with a role in modulating apoptosis and DNA repair. Cross examination of EYA4 expression across multiple tumor types suggests a cell type-specific tumorigenic role for EYA4, consistent with a tumor suppressor function in cancers of epithelial origin. This work shows a clear role for EYA4 as a putative TSG in NSCLC.

Isotretinoin: update on controversial issues

Acne vulgaris is a commonly seen dermatologic condition that plagues millions and can be very psychosocially disabling. Severe and recalcitrant acne is typically treated with isotretinoin. Isotretinoin is a synthetic vitamin A derivative that has been available since 1982.This therapeutic option has been the most effective at putting severe and recalcitrant acne vulgaris into remission. Despite its effectiveness,it has been associated with inflammatory bowel disease, depression, suicidality, and teratogenicity. We review the current literature on isotretinoin's role in inflammatory bowel disease, depression, and suicidality. In addition, we review whether or not the iPledge program has been successful at reducing pregnancy rates while on isotretinoin.

Etiology, diagnosis, and therapeutic management of granuloma annulare: an update

Granuloma annulare (GA) is a common cutaneous disorder classically presenting as annular groups of skin-colored to erythematous papules without epidermal change localized to the dorsal hands and/or feet. In addition to the localized form, there are variants including generalized (including generalized annular GA, disseminated papular GA, and atypical generalized GA), subcutaneous, and perforating GA, providing for a wide spectrum of clinical lesions. The etiology of GA remains unknown and several systemic associations have been proposed but not proven, including diabetes mellitus, malignancy, thyroid disease, and dyslipidemia. The diagnosis of GA relies on clinicopathological correlation, with a skin biopsy confirming the histological features of the disease, including palisading granulomas, collagen degeneration, mucin, and a lymphohistiocytic infiltrate. Localized GA is often asymptomatic and self-limited within 2 years; however, the patient may desire treatment for cosmetic reasons, with topical and intralesional corticosteroids as the mainstays of therapy. When GA is generalized, disseminated, or atypical, a more thorough medical workup for underlying diseases may be considered depending on the physical examination, a thorough review of systems, comorbidities, and clinical suspicion. Treatment is often challenging for generalized GA, especially because of its recalcitrant nature and a lack of evidence-based therapy. Over 30 different treatments have been described for GA with variable results; however, the majority of these have been single case reports, small case series, or retrospective studies. Reported treatments for GA include topical, intralesional, intramuscular, and oral medications (steroidal vs. non-steroidal); biologic agents; surgical interventions; phototherapy; and laser treatments. When selecting a systemic therapy for a patient with GA, multiple variables must be considered, such as baseline blood evaluations, comorbidities, drug interactions, compliance, adverse effect profiles, prior treatments, and reproductive status. This evidence-based review will focus on the advances made in the twenty-first century regarding the etiology, diagnosis, and therapeutic management of GA.