Forum for Nordic Dermato-Venereology No 3, 2019 Telemedicine | Page 26

Dermato-Venereology in the Nordic Countries
Teledermatology and Teledermoscopy: Old Technology Just
Waiting to be Exploited
J ohn P aoli , MD, A ssoc . P rofessor
Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, Uni-
versity of Gothenburg, Gothenburg, Sweden
Over two decades have passed since the first publications on
store-and-forward teledermatology (TD) (1) and teledermosco-
py (TDS) (2) were presented as feasible and useful applications
within telemedicine. The fact that our specialty was chosen as
one of the primary targets for electronic teleconsultations was
not surprising since the absolute majority of dermatological
conditions are visible on the skin surface allowing for digital
photographic documentation. The electronic transmission
of such images together with clinical information between
remote parties for the improvement of patient management
has since then been evaluated in an exponentially increasing
number of clinical settings and studies (Fig. 1). Recent reviews
have shown that TD and TDS avoid unnecessary visits and
reduce waiting times, resulting in earlier assessments and
treatment, improved cost-effectiveness and a high degree of
satisfaction among both patients and users (3–5).
information in the messages was enough to provide adequate
triage decisions by two dermatologists separately in 85% and
95% of the cases (n=40), respectively (6).
In the beginning, images were sent via e-mail, but the true
revolution started with the arrival of high-resolution cameras
in smartphones and user-friendly app software about 10 years
ago. Personally, I got involved in TD and TDS just before Apple
launched their first iPhone ® with third-party apps in 2008. At We soon realized, however, that smartphone apps were
bound to become the future of mobile TD and TDS and were
the first group to create and successfully test a smarthphone
app for store-and-forward TD and TDS in 2011 (7). One year
later, we tested an improved version of this same app (Fig. 2)
in a real-life scenario for patients referred for a suspicion of
skin cancer from 20 primary care centres to two dermatology
departments in a rural and an urban setting, respectively.
We compared the triage decisions made upon assessing 746
traditional referral letters without images with those of 816
smartphone TDS referrals containing one clinical and one
dermoscopic image together with a standardised clinical his-
tory. The triage decisions with TDS were more reliable, >40%
of the patients could potentially have avoided face-to-face
visits and patients with confirmed skin cancer received faster
and more efficient management (8). In 2013, our app was
awarded Dagens Medicin’s prestigious “Gold Scalpel” award
for innovation of the year in Swedish health care (Fig. 3).
that time, my doctoral student Alexander Börve and I started
working on the idea of mobile TD using images taken with
a Sony Ericsson K800 (Sony Ericsson, Lund, Sweden) mobile
phone with a built-in digital camera and sent to dermatologists
via multimedia messaging service (MMS). Despite the small
image size of 680 × 420 pixels, the images and added clinical In order to study the safety, advantages and disadvantages of
TDS for triage of skin cancer referrals, we designed a study to
look further at the diagnostic agreement and the interobserv-
er concordance when more than one teledermatologist was
making the assessments. For this, we used referral information
Fig. 1. The continually increasing number of publications on teleder-
matology and teledermoscopy between 1996 and 2018 (PubMed data). Fig. 2. Images of the first smartphone app for TDS (iDoc24 ® PRO), which
used a digital dermoscope (Handyscope ® , Fotofinder ® ) coupled with an
iPhone ® 4.
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