Forum for Nordic Dermato-Venereology No 3, 2019 Telemedicine | Page 8

Dermato-Venereology in the Nordic Countries Telemedicine for Frostbite Lesions L uit P enninga 1 , A nne K athrine L orentzen 1 M ikkelsen 2,3 and C arsten S auer Ilulissat Hospital, Postbox 514, 3952 Ilulissat, Avannaa Region, Greenland, Clinic in Dermatology, Brønderslev, and 3 Research Lab, Department of Derma- tology, University of Aalborg, and Private Dermatology Practice, Brønderslev, Denmark. E-mail: [email protected] 1 2 Frostbite may cause extensive tissue damage and lead to tis- sue necrosis and amputation of the affected digits or limbs (1). Proper diagnosis and treatment of frostbite lesions is of utmost importance to avoid amputations and tissue loss (2). This requires experience and knowledge regarding diagnosis and optimal treatment of frostbite lesions (2). First and 2 nd -degree frostbite lesions normally heal without tissue loss, while 3 rd or 4 th -degree frostbite lesions often lead to necrosis and amputations/tissue loss (1, 3). The natural course of a severe (3 rd or 4 th degree) frostbite injury is demarcation between viable and non-viable tissue (4). This typically occurs after 1 to 3 months, and ultimately causes auto-amputation, which means that the non-viable tissue falls off without sur- gical intervention. Premature surgical amputation should be avoided, as natural tissue demarcation often reveals a larger amount of viable tissue than would initially be excepted (4). Thus, delayed surgery results in lower levels of morbidity and a better functional result (3). Premature surgery can cause more harm than benefit (4). Therefore, early surgical inter- vention should only be performed in case of uncontrolled infection (4). However, auto-amputation may take up to several months, and surgical amputation may be considered after a certain period of time, once proper demarcation has occurred (4). Telemedicine is widely used for diagnosis and treatment of dermatological diseases (5). Teledermatology includes several modalities like store-and-forward models as well as live video transmissions (6). Advanced cameras with built-in dermoscopes are used, as well as regular cameras and mobile telephones (7). Teledermatology has particularly been success- ful and cost-effective in rural areas with large geographical distances and low population density, for example in Australia, Greenland, Brazil and Afghanistan (8–10). Teledermatology may serve as an excellent modality to ensure high quality guidance and advice for frostbite lesions from regional, national and international experts (4). In this article, we aim to review and summarize the use of teledermatology for frostbite lesions. 92 M ethods We searched Pubmed, the Cochrane library, and Google Scholar for ‘frostbite’, and/or ‘non-freezing cold injuries’ and ‘telemedicine’, ‘teledermatology’ or ‘telehealth’. We included all article types. Reference lists of relevant review articles were searched manually. We applied no language restriction. R esults We found 15 articles related to the use of telemedicine for frostbite lesions (2, 4, 11–23). One case report published in the British Medical Journal in 2004 reports how a British climber developed frostbite of the first toe while climbing Aconcagua, the highest mountain outside the Himalaya mountain range, reaching almost 7,000 m of elevation (11). A local surgeon advised on surgery, but the climber contacted the British Mountaineering Council and uploaded photographs of the frostbitten toe (11). A British surgeon and expert on frostbite injuries reviewed the photographs, and advised against sur- gery. The climber made full recovery without amputation, and needed no surgical intervention during the treatment course (11). The same authors describe in review articles how telemedicine gives access to experts in the field of frostbite and can improve outcomes in frostbite injuries (12, 13). The articles report how teledermatology can be used by both physicians with no prior experience with frostbite, and by non-medical professionals on expeditions, supplying expert advice on the treatment of frostbite lesions, and advice on whether or not to continue the expedition. The British Mountaineering Council has a website where physicians with expert knowledge on frostbite can be contacted with cases and photographs of frostbite injuries, and give diagnostic and therapeutic advice (https://www.thebmc. co.uk/how-to-get-expert-frostbite-advice). This UK-based frostbite service often receives photographs sent by satellite phones from people on expeditions, and has provided help to people in Nepal, India, Pakistan, Argentina, Chile, Namibia, Spain, Peru, Alaska, the Arctic and the Antarctic (14). These authors also report on legal issues regarding medical advice Forum for Nord Derm Ven 2019, Vol. 24, No. 3